1. health and fitness
2. addiction

Therapy Manuals for Drug Addiction Series
Individual Drug Counseling
Delinda E. Mercer, Ph.D.
George E. Woody, M.D.
University of Pennsylvania and
Veterans Affairs Medical Center
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
National Institute on Drug Abuse
Division of Clinical and Services Research
6001 Executive Boulevard
Rockville, Maryland 20892
ACKNOWLEDGMENTS
The development of this manual was supported, in part, by research grants for the
Collaborative Cocaine Treatment Study (CCTS) and for the Drug Dependence Behavioral Treatment Research Center from the National Institute on Drug Abuse
(NIDA). This manual was written by Drs. Delinda E. Mercer and George E. Woody
under contracts with NIDA. Debra Grossman, the NIDA project officer, offered valuable guidance and comments throughout the preparation of this manual.
The material presented in this manual is the result of extensive research and clinical
experience under the direction of Dr. Woody and colleagues at the University of
Pennsylvania (Penn) and Veterans Affairs (VA) Medical Center. The University of
Pennsylvania Center for Psychotherapy Research and the Penn-VA Center for
Studies of Addiction were both instrumental in the development of this manual and
in the Collaborative Cocaine Treatment Study for which this manual was originally
prepared. This drug counseling model is based on the clinical work of Nina
Chychula, Ph.D., John McGinnis, M.S.W., and Debra Wiles, M.S.W., in the Addiction
Recovery Unit of the Veterans Affairs Medical Center under the direction of Iradj
Maany, M.D. The work of many others was also quite valuable and is acknowledged
in the relevant portions of this manual.
The assistance of many dedicated therapists, counselors, and research assistants
who participated in the clinical trial of this therapy protocol is gratefully acknowledged and appreciated.
DISCLAIMER
The opinions expressed herein are the views of the authors and do not necessarily
reflect the official policy or position of the National Institute on Drug Abuse or any
other part of the U.S. Department of Health and Human Services. The U.S. Government does not endorse or favor any specific commercial product.
PUBLIC DOMAIN NOTICE
All material appearing in this report, except the appendix, is in the public domain
and may be reproduced without permission from the Institute or the authors. Citation of the source is appreciated.
NIH Pub. No. 99–4380
Printed September 1999
Foreword
More than 20 years of research has shown that addiction is clearly treatable. Addiction treatment has been effective in reducing drug use and HIV
infection, diminishing the health and social costs that result from addiction, and decreasing criminal behavior. The National Institute on Drug
Abuse (NIDA), which supports more than 85 percent of the world’s research on drug abuse and addiction, has found that behavioral approaches can be very effective in treating cocaine addiction.
To ensure that treatment providers apply the most current scientifically
supported approaches to their patients, NIDA has supported the development of the “Therapy Manuals for Drug Addiction” series. This series reflects NIDA’s commitment to rapidly applying basic findings in real-life
settings. The manuals are derived from those used efficaciously in
NIDA-supported drug abuse treatment studies. They are intended for use
by drug abuse treatment practitioners, mental health professionals, and
all others concerned with the treatment of drug addiction.
The manuals present clear, helpful information to aid drug treatment
practitioners in providing the best possible care that science has to offer. They describe scientifically supported therapies for addiction and
give guidance on session content and how to implement specific techniques. Of course, there is no substitute for training and supervision, and
these manuals may not be applicable to all types of patients nor compatible with all clinical programs or treatment approaches. These manuals
should be viewed as a supplement to, but not a replacement for, careful
assessment of each patient, appropriate case formulation, ongoing monitoring of clinical status, and clinical judgment.
The therapies presented in this series exemplify the best of what we currently know about treating drug addiction. As our knowledge evolves,
new and improved therapies are certain to emerge. We look forward to
continuously bringing you the latest scientific findings through manuals
and other science-based publications. We welcome your feedback about
the usefulness of this manual series and any ideas you have on how it
might be improved.
Alan I. Leshner, Ph.D.
Director
National Institute on Drug Abuse
iii
iv
Contents
Page
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Chapter 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Research Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Treatment Philosophy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Contributions of the 12-Step Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Role of Self-Help Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Role of Significant Others in Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Chapter 2 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Overview of This Counseling Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Comparison of Addiction Counseling and Psychotherapy. . . . . . . . . . . . . . . . . 7
Similar and Dissimilar Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Compatibility With Other Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Chapter 3 Logistics of the Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Frequency and Duration of Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Duration of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Target Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Chapter 4 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Addiction Severity Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Biological Assays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Chapter 5 The Role of the Addiction Counselor . . . . . . . . . . . . . . . . . 17
Patient-Counselor Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
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Behaviors That Should Not Be Done . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Chapter 6 The Individual Drug Counseling Model . . . . . . . . . . . . . . . 21
Goals and Objectives of Individual Drug Counseling . . . . . . . . . . . . . . . . . . . 21
Stages of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
In Each Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Preparing for the Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
During Each Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Chapter 7 Treatment Initiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Treatment Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Ambivalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Introductory Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Session 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Session 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Chapter 8 Early Abstinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Treatment Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Addiction and the Associated Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . 30
People, Places, and Things . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Structuring One’s Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Sample Schedules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Craving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
High-Risk Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Social Pressures To Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Compulsive Sexual Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Postacute Withdrawal Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Use of Other Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
12-Step Participation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Chapter 9 Maintaining Abstinence . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Treatment Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Tools for Preventing Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Identification of the Relapse Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Relationships in Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Development of a Drug-Free Lifestyle . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Spirituality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Shame and Guilt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Personal Inventory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Character Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
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Identification and Fulfillment of Needs . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Management of Anger. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Relaxation and Leisure Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Employment and Management of Money. . . . . . . . . . . . . . . . . . . . . . . . . 58
Transfer of Addictive Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Chapter 10 Advanced Recovery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Treatment Booster Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Goals of Booster Sessions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Chapter 11 Dealing With Problems That Arise . . . . . . . . . . . . . . . . . . 63
Dealing With Lateness or Nonattendance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Denial, Resistance, or Poor Motivation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Strategies for Dealing With Crises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Dealing With Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Levels of Severity of Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Slips. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Several Days of Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Sustained Drug Use With Resumption of Addiction. . . . . . . . . . . . . . . . . 66
Chapter 12 Counselor Characteristics and Training. . . . . . . . . . . . . . 67
Ideal Personal Characteristics of the Counselor. . . . . . . . . . . . . . . . . . . . . . . . 67
Educational Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Credentials and Experience Required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Counselors in Recovery Themselves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Chapter 13 Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Training and Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Use of the Adherence Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Appendix: Adherence/Competence Scale for Individual
Drug Counseling (IDC) for Cocaine Dependence . . . . . . . . . . . . . 77
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Chapter 1 Introduction
Introduction
This manual is intended as a guide for the individual treatment of cocaine addiction by addiction counselors. The counseling model described here was developed originally for use in the Collaborative Cocaine Treatment Study (Mercer and Woody 1992) sponsored by the National Institute on Drug Abuse. This model was based on the counseling
in the outpatient, drug-free program in the Addiction Recovery Unit and
in the methadone maintenance program (Woody et al. 1977), which are
both part of the Veterans Affairs Medical Center. Twelve-step philosophy
and participation is a central component of the model. Additionally, we
have drawn upon the ideas of many clinicians and theorists in this area,
including Alan Marlatt (Marlatt and Gordon 1985), Terrence Gorski
(Gorski and Miller 1982), Dennis Daley (1986, 1988, 1993), and Arnold
Washton (1990a, 1990b, 1990c).
This individual counseling model can be viewed as a component within
a comprehensive outpatient treatment program for cocaine addiction.
Alternatively, the model can be offered independently of other treatments, and referrals can be made for any additional services as needed.
Research Support
The Collaborative Cocaine Treatment Study (Crits-Christoph et al.
1997) was a large study carried out at four sites in the northeastern
United States that investigated the relative efficacy of four psychosocial
treatments for cocaine addiction. The individual drug counseling model
presented in this manual was developed for use in the study protocol.
Four hundred and eighty-seven cocaine-addicted adults were randomly assigned to individual drug counseling (IDC) plus group drug
counseling (GDC), cognitive therapy (CT) plus GDC, supportive-expressive psychodynamic therapy (SE) plus GDC, or GDC alone
(Crits-Christoph et al. 1997). Individual treatment sessions were offered twice weekly for 3 months, then once weekly for 3 months.
Group sessions were once a week for 6 months. Results showed that
patients in all treatment conditions reduced their cocaine use signifi1
Chapter 1 Introduction
cantly; however, patients in IDC reduced their cocaine use more and
did so more rapidly than those in the other conditions (Crits-Christoph
et al. in press).
Treatment Philosophy
According to the philosophy underlying the IDC approach, addiction is
a complex disease that damages the addict physically, mentally, and spiritually. Because of the holistic nature of the illness, the optimal treatment addresses the needs of the addict in many areas. Physical, emotional, spiritual, and interpersonal needs must all be addressed to support recovery.
The philosophy of this approach incorporates two important elements:
endorsement of the disease model and the spiritual dimension of recovery. These elements differentiate the approach from some other forms
of treatment currently in use and reflect the influence of the 12-step
philosophy.
The disease model essentially states that addiction is more closely akin
to an illness over which one has little, if any, control, compared to a behavior that one chooses to enact. Recent biologically oriented research
suggests a genetic component to alcohol and other addictions and
points to physiological changes in the brain that result from drug use.
These findings are very consistent with the disease model (Bloom 1992;
Heinz et al. 1998).
The element of spirituality is very general and not specific to any religion. Three of the main spiritual principles, as taken from Narcotics
Anonymous (NA) philosophy, are honesty, openmindedness, and willingness. This spiritual component implies that there is a healing of one’s
life that needs to take place, and abstinence from the drug is merely the
first step rather than the terminal goal. A holistic perspective on the individual is encouraged, which suggests that recovery involves a return to
self-respect through honesty with oneself and others. Spirituality also
involves a belief in or sense of connection to something greater than
oneself, which is quite consistent with some of the newer models of psychotherapy. However, within addiction counseling, the role of spirituality in healing tends to be more focused and overtly stated than in most
other therapeutic orientations.
Contributions of the 12-Step Approach
Numerous authors (e.g., Galanter and Pattison 1984; Washton 1989)
have suggested that 12-step groups play an important role in addiction
treatment. Historically, 12-step treatment programs are linked largely to
recovery from alcohol abuse and addiction, which is a logical associa2
Chapter 1 Introduction
tion. Since its inception in 1935, more than 1 million persons are estimated to have achieved recovery through involvement in Alcoholics
Anonymous (AA) programs. Additionally, it is estimated that, at any one
time, more than 100,000 men and women worldwide are involved in AA
12-step programs (AA World Services, Inc. 1986).
However, neither the 12-step philosophy nor its procedures are related
intrinsically to alcohol. AA has spawned many related programs for recovery from other addictions or other emotional problems. Narcotics
Anonymous is a 12-step program adapted from AA. The primary difference between the two is that NA is more inclusive with respect to addiction to any mood-altering substance. Cocaine Anonymous (CA) is a
smaller group geared specifically to cocaine addiction, as the name implies. NA and CA, like the many other 12-step programs AA has spawned,
adhere to the same philosophy and beliefs as AA. The underlying belief is
that most aspects of chemical addiction are transcendent rather than
specific to any particular drug.
Twelve-step ideology offers patients seeking recovery a new modus vivendi, or way of living, that will support them in breaking the cycle of addiction and in maintaining abstinence. The strengths and usefulness of
the 12-step approach seem to have several sources. Procedurally, virtually any presenting situation can be dealt with effectively by applying the
appropriate lesson or lessons derived from the more than 60 years of
honing and refining the 12-step philosophy.
Essentially, these steps provide a developmental approach for recovering from addiction. The steps are organized in an order, going from the
most basic changes onward to the more advanced changes that individuals motivated to recover may seek to integrate into their life. Narratives
of others who are struggling with addiction offer compelling perspectives to support the individual seeking recovery. These narratives help
addicts to confront the reality of their addiction and recognize the harm
it has done to them personally and to the people they care about. The approach also asks addicts to recognize the existence of a higher power
and to incorporate this belief in their own lives, if only for the reason
that it has been shown to be helpful in aiding recovery (Galanter and
Pattison 1984).
Role of Self-Help Groups
Participation in a self-help program is probably not for everyone but for
many is an extremely valuable aid to recovery. Such participation helps
recovering individuals to develop a social support network outside of
their treatment program, teaches the skills needed to recover, and helps
patients to take responsibility for their own recovery. Participation in a
group provides a sense of belonging and can lead to a new identity for
3
Chapter 1 Introduction
individuals whose primary identity has been as an alcoholic or drug addict.
In the Collaborative Cocaine study, we studied pretreatment self-help
group attendance to see if it would predict initiation of abstinence in
519 cocaine-addicted patients entering treatment (Weiss et al. 1996). Of
the 519 respondents, 34 percent indicated that they had attended at
least one 12-step meeting in the past week. Of those who attended, 85
percent actively participated in program activities in some way, such as
reading 12-step literature, meeting with one’s sponsor, or speaking at a
meeting. We found that 51 percent of self-help attendees initiated abstinence, compared to 40 percent of nonattendees, a significant difference. Furthermore, active participation appears to be more helpful than
merely attending meetings: 55 percent of active participants became abstinent, compared to 38 percent of attendees who did not actively participate and 40 percent of nonattendees. AA and NA were the most frequently attended self-help groups, which may be because they are more
widely available than CA and some of the other 12-step organizations.
In addition to encouraging patients to attend self-help groups at least
three times a week and to get a sponsor, the addiction counseling program educates patients about 12-step ideology and incorporates many
of the 12-step concepts into the content of the counseling. By introducing and promoting many of the 12-step concepts, the program exposes
the ideas to patients who are unwilling to participate in meetings at that
juncture. Addressed within the content of the counseling sessions are
such concepts as breaking through denial; avoiding people, places, and
things that can trigger drug craving; taking a personal inventory; working on character defects; and incorporating spirituality as an element of
recovery.
Regarding 12-step versus other types of programs, participation in any
legitimate self-help program should be encouraged. Patients may gravitate toward a variety of non-12-step-based self-help groups, such as Rational Recovery, Women for Sobriety, or individual religious groups, depending upon their individual preferences. The selection is limited primarily by what is available locally. However, the 12-step approach to recovery is generally more well known, and such groups are more widely
available than other approaches. For mainly this reason, it has been an
integral part of many addicts’ recovery. Thus, we focus more on 12-step
programs than on other groups and draw from this approach in the
counseling itself.
Role of Significant Others in Treatment
This model of addiction counseling does not focus much attention on
the role of family members in treatment. The reason is not because family involvement is seen as unimportant in treatment, but rather because
4
Chapter 1 Introduction
IDC is not intended to provide all-inclusive treatment. Family members
can play an important role in recovery.
In general, including partners, family members, and even close friends
in addiction treatment, e.g., in the form of holding family sessions, can
facilitate recovery. Encouraging family involvement can help the recovering person create a better, more knowledgeable support network
(Galanter 1986). It may decrease the family’s addiction-enabling and/or
codependent behaviors that tend to impede the patient’s recovery. And
it will make it easier for the counselor to intervene in any problematic
family situations that might potentiate a relapse.
5
6
Chapter 2 Overview
Overview of This Counseling Approach
Individual drug counseling focuses on the symptoms of drug addiction
and related areas of impaired functioning and the content and structure
of the patient’s ongoing recovery program. This model of counseling is
time limited and emphasizes behavioral change. It gives the patient coping strategies and tools for recovery and promotes 12-step ideology and
participation. The primary goal of addiction counseling is to assist the
addict in achieving and maintaining abstinence from addictive chemicals and behaviors. The secondary goal is to help the addict recover from
the damage the addiction has caused in his or her life.
Addiction counseling works by first helping the patient recognize the existence of a problem and the associated irrational thinking. Next, the patient is encouraged to achieve and maintain abstinence and then to develop the necessary psychosocial skills and spiritual development to
continue in recovery as a lifelong process.
Within this counseling model, the patient is the effective agent of
change. It is the patient who must take responsibility for working on and
succeeding with a program of recovery. Although recovery is ultimately
the patient’s responsibility, the patient is encouraged to get a great deal
of support from others, including counselors and other treatment staff,
one’s sponsor, and drug-free or recovering peers and family members.
Overall, drug use is thought to be a multidetermined, maladaptive way
of coping with life’s problems. It sometimes becomes compulsive and
leads to a progressive deterioration in one’s life circumstances. Compulsive drug abuse is addiction, which is defined as a disease. It damages the
addict physically, mentally, and spiritually.
Comparison of Addiction Counseling and Psychotherapy
In the research protocol for which IDC was developed originally, it was
extremely important to clarify the boundary between addiction counseling and psychotherapy. Addiction counseling and psychotherapy were
compared to determine if one was more effective than the other for the
7
Chapter 2 Overview
treatment of cocaine addiction. In clinical practice, however, the boundary between addiction counseling and psychotherapy often is blurred.
To aid understanding of the contrast between addiction counseling and
psychotherapy, the elements of addiction counseling that may differ
from psychotherapy are discussed here.
Addiction counseling involves setting and encouraging the patient to
work toward predominantly short-term goals. Although the goal of continued abstinence supported by a change in lifestyle is not short-term,
the 12-step adage of “one day at a time” creates a short-term way of working toward lifestyle change.
The goals of IDC are always directly related to recovery from addiction.
For example, an appropriate goal in addiction counseling might be for
the patient to terminate an abusive relationship that enabled the patient’s drug use, but it would not be an appropriate treatment goal for
the patient to work through issues stemming from his or her early abusive relationship with a parent. Another appropriate goal of addiction
counseling would be to recognize the impact of one’s dysphoric feelings
on one’s drug use and to develop a strategy for responding in a new way
that does not involve drug use. However, it would not be appropriate to
do a cognitive analysis of the thoughts that underlie the dysphoria. The
addiction counselor tries to provide the patient with concrete, behavioral options to facilitate recovery. Such options include avoiding those
things that trigger drug use, attending self-help groups, and leaving or
changing situations or relationships that contribute to the addiction.
Finally, addiction counseling focuses primarily on the present rather
than the past. The counselor might become familiar with some of the significant historical data but would not direct interventions aimed at understanding the effects of past events, except perhaps those events that
are related to the addiction.
Below is a comparison of addiction counseling with a typical model of
psychotherapy, which would include psychodynamic approaches and
cognitive therapy, as well as other approaches. However, not all models
of psychotherapy are consistent with this simplified model.
8
Addiction Counseling
Psychotherapy
Short-term goals
Short- and long-term goals
Behavioral goals
Cognitive, emotional, and
behavioral goals
Goals directly related to
addiction
Goals related to all areas of
recovery
Focus on the present
Focus on the past and present
Chapter 2 Overview
Similar and Dissimilar Approaches
Several other approaches used in addiction treatment are quite similar
to the model of counseling presented here. Probably the most similar is
the Minnesota Model, or what often is referred to as the Hazelden approach. Another popular drug counseling approach that is quite similar
is the CENAPS model (Gorski 1989). The 12-step facilitation model
(Nowinski et al. 1994), developed for use in the MATCH study (Project
MATCH Research Group 1993) sponsored by the National Institute on
Alcohol Abuse and Alcoholism, also is similar in its emphasis on the
12-step philosophy and participation.
Other approaches are more dissimilar, such as the traditional
Synanon-style approach as provided in a therapeutic community. The
difference is not in the content, which might, in fact, be similar, but in
the format which, in the therapeutic community situation, would probably be more structured, punitive, and confrontational. Also, our approach is tailored for use in outpatient treatment, so there is no opportunity for immersion in a community, which usually is regarded as a
powerful intervention. Another approach that would be dissimilar in
both philosophy and content would be any psychotherapy model that
does not focus primarily and specifically on changing addictive behaviors, such as psychoanalytic or psychodynamic therapies, including supportive-expressive therapy (Luborsky 1984; Mark and Luborsky 1992)
and interpersonal therapy (Rounsaville et al. 1985).
Compatibility With Other Treatments
This counseling approach is highly compatible with most other treatments for addiction. It fits well with many other treatments because it
was designed to be a component in a more comprehensive treatment
package. Such a treatment program would probably include initial medical and psychosocial assessments, detoxification if necessary, participation in group therapy, psychiatric and medical services if needed, a family support group, possibly employment counseling, and ongoing participation in a self-help program along with the individual addiction
counseling. However, this approach to addiction counseling also lends
itself well to being used in a private practice format where other types of
treatment could be added as desired. For example, it might be combined with family or couples therapy or alternative therapies.
The model can be coordinated easily with pharmacotherapy approaches, whether for treatment of addiction or comorbid psychiatric
disorders. While addiction counseling is provided for treatment of cocaine addiction, it is not unusual for patients also to receive antidepressant medication for comorbid depression. Similar counseling also has
been used in combination with naltrexone prescribed for alcohol addic9
Chapter 2 Overview
tion. A trickier situation occurs when a patient being treated for chemical addiction also is being treated for a psychiatric problem with a potentially addictive medication. For example, a patient with cocaine addiction and comorbid panic disorder might be treated legitimately for the
panic with a benzodiazepine. In such cases, it is especially important to
monitor the use of medication to ensure that it is used appropriately. It
is also important, when any medication is being prescribed, to clarify for
the patient that being free of any mood-altering chemicals is not intended to include legitimately prescribed medications.
10
Chapter 3 Logistics of the Model
Frequency and Duration of Sessions
The optimal frequency for counseling sessions is twice a week, at least
initially. More than twice a week may be a burden for the patient who is
functioning well enough to be employed and have a family or other social supports. Less than twice a week can be too infrequent to create a
strong sense of connection and support and provide the monitoring
that is helpful for the person who is struggling with recovery. The necessary frequency depends largely on the amount of structure and support
that already exist in the patient’s life and how able the patient is to create
structure and engage in healthy activities.
When the IDC model was developed for research, the counseling sessions took place twice a week from the first week through the twelfth
week and then decreased to once a week from the thirteenth week
through the twenty-fourth week of treatment. Following completion of
the active treatment phase at 24 weeks, less frequent booster sessions
were provided. Booster sessions usually help patients to retain the gains
they have made longer. Even infrequent check-in sessions, perhaps once
a month, tend to remind patients of the goal and help them feel supported and monitored.
Weeks
Sessions per week
1–12
13–24
25–36
2
1
0.25
In the IDC model, each session should be approximately 45 minutes,
unless the patient arrives late, thus causing the session to be curtailed.
The counselor is responsible for scheduling sessions and for dealing
with any missed appointments by promptly contacting the patient and
rescheduling. If the patient cancels a session, the counselor should offer
another appointment as soon as possible. The counselor should always
be prompt and keep in mind that the counseling relationship is a professional one and that the patient deserves to be treated with respect.
11
Chapter 3 Logistics of the Model
Duration of Treatment
This model is intended to be time limited, with 36 sessions planned to
occur over 6 months. It is difficult to determine what is the optimal
amount of addiction counseling, or of any therapy for that matter, because so much depends upon the motivation and progress of the patient. Six months is a fairly generous time allotment, longer than some
programs, however shorter than is probably standard in a private practice model of treatment. There is a benefit to offering a time-limited
treatment as it can help the patient to structure his or her recovery
knowing that there are only so many sessions. In time-limited therapy,
the counselor should highlight the length of the treatment in the introductory sessions, and the patient and therapist should complete treatment plans and review goals with this time frame in mind. Also, when
the patient nears the time of termination, the counselor should remind
the patient of the limit. In the terminating process, the counselor and
patient should establish plans or goals, so that the patient is left with a
clear idea of where to go after treatment ends.
Target Population
IDC has been developed for adult male and female outpatient cocaine
addicts. Individuals can be abusing or addicted to other drugs in addition to cocaine, with the exception of opiates if methadone maintenance
is to be used. Similar counseling would be appropriate for methadone-maintained, cocaine-addicted patients, with modifications recognizing the issue of being in drug maintenance therapy. Also, while this
particular approach specifically addresses cocaine addiction in describing postacute withdrawal symptoms and so forth, all of the general
themes (everything excluding specific information about cocaine) are
appropriate for use in treating other drug addictions as well.
Some individuals need more than IDC or other addiction-focused treatment. For example, dually diagnosed individuals with significant
psychopathology often require more attention to their psychopathology
than this approach provides. However, the approach can be used in
combination with pharmacotherapy for other psychiatric problems or
sometimes is employed as part of a package in which a counselor focuses
on the addiction and another clinician, usually a psychologist or psychiatrist provides psychotherapy and/or pharmacotherapy to address other
psychiatric problems.
Setting
This model was developed for use as part of an outpatient addiction
treatment program and could be used easily in a private practice setting.
12
Chapter 3 Logistics of the Model
It also could be adapted for use in an inpatient program or intensive day
treatment program. To do so would involve retaining the structure and
content of the sessions but modifying their frequency and the overall
length of the treatment. IDC is planned to span 6 months and offer 36
sessions during the active treatment phase and then provide
once-a-month followup sessions for 3 months. Usually inpatient and intensive day treatments are briefer, but there is opportunity for counseling to be provided more frequently.
13
14
Chapter 4 Assessment
Assessment
Treatment entry necessarily involves a relatively comprehensive assessment of the patient’s condition and specific problems or needs, including medical, psychiatric, and psychosocial status. Often for research protocols, the assessment is completed formally by research staff prior to
the start of counseling. However, in many other settings, the counselor
will be responsible for completing the psychosocial assessment in conjunction with the gathering of history in the initial one or two sessions.
Addiction Severity Index
The main assessment instrument that is used routinely with addiction
counseling is the Addiction Severity Index (ASI) (McLellan et al. 1992).
This interview examines drug use and related problems over the past 30
days, so it is typically completed when the patient enters treatment to establish a baseline and identify areas of need and then at selected
followup points thereafter to measure change. The ASI measures seven
addiction-related domains: drug use, alcohol use, medical problems,
psychiatric problems, legal problems, family/social problems, and employment/ support problems. It requires approximately 45 minutes for
the initial administration and about 25 to 30 minutes for each followup
administration.
Biological Assays
The only ongoing assessment procedures that are necessarily a part of
addiction counseling are self-reports of drug use corroborated by some
form of biological assay. The most commonly used drug screening test is
urinalysis, which can test for drugs of abuse, as well as many medications. Typically, laboratories will screen for a panel of drugs that are
commonly abused, including opiates, cocaine, benzodiazepines, amphetamines, barbiturates, and cannabis. Specific opiates and
benzodiazepines can be identified when a patient is receiving an opiate
or a benzodiazepine for a medical purpose, such as methadone maintenance, but also abuses heroin. The different drugs of abuse or their
15
Chapter 4 Assessment
metabolites remain in the urine for differing lengths of time. Typically,
alcohol is tested via Breathalyzer® because of the convenience, minimal
expense, and immediacy of this method. There are other methods, such
as saliva, hair, and blood tests, which have some advantages and disadvantages but generally are less widely used in drug treatment.
In the treatment of an addicted person in an outpatient setting, the patient’s self-reports should be corroborated with urinalysis or some other
form of biological assay. The counselor has much greater ability to monitor the patient’s recovery and to be more certain of the patient’s honesty
in reporting drug use. Usually, patients feel that the counselor’s careful
monitoring supports their recovery because it discourages them from lying to themselves or others about any drug use. Also, patients struggling
with recovery often appreciate the concrete feedback that urine screens
provide. The counselor always should remember to give feedback on
drug tests as promptly as possible and definitely should take every opportunity provided by a clean drug screen to compliment the patient on
his or her progress.
16
Chapter 5 The Role of the Addiction
Counselor
Patient-Counselor Relationship
The role of the counselor in addiction treatment is to provide support,
education, and nonjudgmental confrontation. The counselor must establish good rapport with the patient. The patient recovering from
chemical addiction deserves to feel understood and that he or she has an
ally. The counselor wants to convey to the patient that he or she appreciates the difficulty of this struggle and the need for support through the
recovery process.
The metaphor of the hiker and the guide is useful for conceptualizing
the counselor-patient relationship. The counselor guides the patient
through at least the early stages of recovery, but the recovery process ultimately belongs to the patient. It is the patient alone who is responsible
and accountable for his or her recovery. The counselor must emphasize
this point to facilitate personal responsibility. Confronting the patient
may be useful to emphasize personal responsibility. However, when
confrontation is necessary, the counselor should convey a supportive
rather than a punitive attitude.
The counselor must find a balance between being directive and allowing
the patient to be self-directed. This process is facilitated if the counselor
imposes a structure on the session that includes giving the patient feedback about the most recent urine drug screens and about the patient’s
progress in recovery and evaluatively processing any episodes of use or
near use. The counselor identifies the relevant topic for discussion,
based on what the patient seems to need, and introduces that topic. At
times, the counselor may directly pressure the patient to change certain
behaviors, perhaps, as an example, to start attending 12-step meetings.
However, the patient also is encouraged to be self-directed. For example, within the framework of a particular topic, perhaps coping with
“social pressure to use,” the patient may explore how to manage this
problem best, and the counselor will respond to the patient’s direction. If the patient seems unable to change some aspect of addictive behavior—for example, being around dangerous situations—the
17
Chapter 5 The Role of the Addiction Counselor
counselor should accept where the patient is and assist the patient
to explore those perceptions or situations in a way that might allow
himself or herself to do it differently, i.e., in a better way, the next
time. However, the counselor should discourage regressive or other
movements that lead back toward addiction. A balance needs to be
struck so there is respect for the patient and acceptance of where he
or she is and continual, ongoing pressure in the direction of abstinence and recovery.
Therapeutic Alliance
The counselor should create a sense of participating in a collaboration and partnership. This goal is best accomplished through three
main avenues of approach. First, the counselor should possess a
thorough knowledge of addiction and the lifestyles of addicts. Second, no matter how expert the counselor is, he or she must acknowledge that the patient is the true expert in discussing his or
her own life. The counselor must listen accurately, empathize effectively, and avoid passing judgment. Third, the counselor should
convey to the patient that he or she has an ally in the difficult progress toward recovery. Each of these approaches should help
strengthen the therapeutic alliance and make the relationship a
collaborative one.
Generally, the interventions that are most helpful in fostering a
strong therapeutic alliance are those that involve the counselor’s active listening and those that emphasize collaboration (Luborsky et al.
1997). For example, after the patient reports a relapse, the counselor
might say, “Let us examine what happened and together develop a
plan to help you avoid using next time.” Such language highlights the
combined effort in the relationship.
If the therapeutic relationship initially seems weak, the counselor
might use the following simple strategy to address the problem: Ask
the patient what is not working in the relationship or what the patient
thinks is causing it not to work. Often the patient knows full well what
might improve the therapeutic relationship but, for whatever reason,
does not feel comfortable enough to mention it until the counselor
initiates the topic. For improvement to occur, the counselor should
be willing to accept feedback from the patient and possibly change
the approach. However, in responding to a patient’s request to
change, the counselor should not feel pressured to change, or in any
way compromise, his or her philosophy of addiction treatment.
Rather, the counselor may adjust his or her interpersonal style to improve the working alliance.
18
Chapter 5 The Role of the Addiction Counselor
Behaviors That Should Not Be Done
The counselor should not be harshly judgmental of the patient’s addictive behaviors. After all, if the patient did not suffer from addiction, he or
she would not need drug counseling, so blaming the patient for exhibiting these symptoms is useless. Also, patients often feel a great deal of
shame associated with their addictive behaviors. In order to help resolve
those feelings of shame and guilt, the counselor should encourage the
patient to speak honestly about drug use and other addictive behaviors
and be accepting of what is said.
The counselor should be respectful of the patient. The counselor should
always be professional, including not being late for appointments and
never treating or talking to the patient in a derogatory or disrespectful
manner. Moreover, the counselor should avoid too much
self-disclosure. While occasional appropriate self-disclosure can help
the patient to open up or motivate the patient by providing a role model,
too much self-disclosure removes the focus from the patient’s own recovery. A good rule for when to self-disclose, if the counselor is indeed
so inclined, is for the counselor first to have a clear purpose or goal for
the intervention and then to analyze why he or she is choosing to
self-disclose at this particular time. If any doubt results from this analysis, it probably should lead to a more conservative, nondisclosure position.
Lastly, counselors need to be aware of when their own issues are stimulated by a patient’s problems and refrain from responding from the context of their own personal issues. For example, consider the case where
a counselor in recovery feels that it was extremely important for him or
her to break ties with addicted peers. Now this counselor is working
with a particular patient who has an addicted spouse or partner and
does not want to break these relationship ties. It is imperative that the
counselor be flexible and respond creatively to the patient’s own perception of the problem. In this case, the counselor must not rigidly adhere to the notion of insisting that breaking ties with all addicts is the
only acceptable path to recovery. In general, the reflexive, noncritical
projection of the counselor’s own needs or experiences onto that of the
patient’s situation can be damaging or, at least, counterproductive.
19
20
Chapter 6 The Individual Drug
Counseling Model
Goals and Objectives of Individual Drug Counseling
Addiction counseling addresses (1) the symptoms of the drug addiction and areas of impaired functioning that are related to it and
(2) the content and structure of the patient’s ongoing recovery program. Throughout the course of counseling, the addiction counselor
will:
1.
Help the patient to admit that he or she suffers from the disease of
chemical addiction.
2.
Point out the signs and symptoms of addiction that are relevant to
the patient’s experience.
3.
Teach the addict to recognize and rechannel urges to use drugs.
4.
Encourage and motivate the patient to achieve and sustain abstinence.
5.
Monitor and encourage abstinence by using objective measures,
such as urinalysis and Breathalyzer® tests.
6.
Hold the chemically addicted person accountable for and discuss
any episodes of use and strongly discourage further use.
7.
Assist the patient in identifying situations where drugs were used to
cope with life’s problems and in understanding that using drugs to
cope with or solve problems does not work.
8.
Help the addict to develop new, more effective problem-solving
strategies.
9.
Introduce the patient to the 12-step philosophy and strongly encourage participation in NA, AA, and/or CA.
21
Chapter 6 The Individual Drug Counseling Model
10. Encourage the chemically addicted person to develop and continue
with a recovery plan as a lifelong process.
11. Help the addict to recognize and change problematic attitudes and
behaviors that may stimulate a relapse.
12. Encourage the patient to improve self-esteem by practicing newly acquired coping skills and problem-solving strategies at home and in
the community.
The drug counseling sessions have a clear structure. However, within
the framework of that structure, the content of the discussion is largely
up to the patient. We make an effort to address effectively the patient’s
individual needs at any point in treatment while also recognizing the
commonality of many issues in addiction and recovery. People are indeed unique; however, the facets of a human problem like cocaine addiction usually follow familiar patterns. The validity of both realities
should be respected.
Stages of Treatment
The stages of addiction treatment described here are:
1.
Treatment Initiation
2.
Early Abstinence
3.
Maintenance of Abstinence
4.
Advanced Recovery
As with other stage theories of development, the stage theory of addiction recovery is only a model. Individuals pass through the stages at their
own pace, the stages are overlapping rather than discreet, and individuals may slip back at points and need to rework issues from previous
stages. This theory does not, however, discount the considerable usefulness of having a model of the typical process in mind so that the patient’s
place in his or her own recovery then can be compared with the model
for better understanding the patient’s process and the steps needed to
be taken to proceed.
Appropriate treatment for chemical addiction varies and is sensitive and
responsive to the changing needs of the patient throughout his or her recovery. The addiction counselor should understand that addiction treatment must be progressive, just as the patient’s recovery process is progressive. To provide optimal counseling, the counselor must be sensitive to the patient’s evolving needs in treatment. To ensure a progressive
approach to addiction treatment, the counselor must be prepared to
22
Chapter 6 The Individual Drug Counseling Model
address different topics in recovery, use different kinds of interventions,
and hold the patient to a different level of responsibility as he or she
works toward recovery.
In Each Session
Preparing for the
Session
During Each Session
The counselor should prepare for each session by checking the patient’s
recent urine results and recalling the major themes or issues from the
previous session. The counselor must understand the progressive nature of treatment and be familiar with the topics that are appropriate to
the patient’s current phase in recovery. In summary:
1.
Check urine results.
2.
Recall themes from previous session.
3.
Prepare to discuss the topics appropriate to the patient’s phase in
treatment.
At the beginning of each session, the counselor should inquire how
things have been going since the last session and whether the patient has
used any drugs. Reported drug use should be noted. If the patient relapses, the patient and counselor should analyze the relapse, determine
what precipitated it, and develop alternatives that can be used to avoid
relapsing again. This process will probably require the full session.
If the patient presents with an urgent, addiction-related problem like
family arguments or financial problems as a result of the addiction, the
counselor should address these problems in the session. Emphasis
should be on how these problems are related to the addictive behavior.
The counselor’s goal is to help the patient develop strategies for dealing
with the problems without turning to drugs. For example, the loss of
one’s job, the serious illness of a loved one, or severe relationship problems will require acknowledgment and some attention in the counseling session. However, the main purpose of the session is the promotion
of recovery from addiction, not the resolution of the patient’s other life
problems.
The counselor should always give the patient feedback regarding the
most recent drug screen results. If the urine test was positive for cocaine, the counselor should confront the patient with this information.
Even if the patient has admitted to recent use, the counselor should discuss the urinalysis result, so the patient is reassured that the counselor is
monitoring his or her efforts to abstain. If, however, the patient denies
any use even though the urine sample is positive for cocaine (which is
not uncommon), the counselor should view this behavior as most likely
23
Chapter 6 The Individual Drug Counseling Model
indicative of denial, underlying which might be feelings of shame. The
counselor will probably want to use themes of shame or denial in addressing this disparity.
A useful approach is discussing how the patient would feel and what it
would mean if he or she were using drugs. If the patient continues to
insist that there has been no cocaine use, the counselor probably should
just drop the matter and agree to disagree for the present. Continuing to
confront without moving the counseling anywhere probably is unwise
because the counselor risks severing the therapeutic connection. If the
patient insists that there is some type of laboratory error, the counselor
may be able to split the urine and have half analyzed with a different test,
or use a different screening procedure, such as a saliva test.
If nothing urgent must be addressed in the session, the counselor and
patient should discuss the addiction-related topic(s) most relevant to
the patient’s current needs in recovery. The topics central to recovery
from cocaine addiction, and the stage of recovery they are particularly
associated with, are described in the next section. No more than two
new topics should be introduced to the patient in a session. However,
any topics that have already been introduced to the patient can be reviewed, if appropriate.
To review, in each session, the counselor should:
24
1.
Find out how the patient has been since last session.
2.
Inquire whether the patient has used drugs since last session.
·
If the patient has used cocaine, analyze the relapse and develop
strategies to prevent future relapses.
·
If the patient has used other drugs, discuss why abstaining from all
drugs is important, particularly when one is attempting to recover
from chemical addiction.
3.
Inquire whether there are any urgent problems that need attention
and, if so, deal with them.
4.
Provide feedback about whether recent urine tests have come back
showing any cocaine use or not.
5.
Discuss the recovery topic that is most relevant to the patient’s stage
in recovery and his or her particular needs in treatment.
Chapter 7 Treatment Initiation
Patients often enter treatment with ambivalence about giving up their
drug use. Counseling begins with helping the addict decide to participate
in treatment and accept abstinence as a goal. The counselor can help the
patient recognize and understand the damaging effects of addiction, address his or her denial of the problem, and show motivation toward recovery. In this progressive treatment model, the patient’s ambivalence is discussed specifically in the first 2 weeks of treatment, although motivation
and commitment to recovery may be issues that are returned to throughout treatment.
The first two sessions of counseling should be devoted to introducing
the treatment program to the patient, obtaining a drug usage and treatment history, and developing the treatment plan with the patient. Because of their specific purpose in establishing the overall framework for
the provision of treatment, these sessions are described in some detail.
Counselors should follow the session agenda described. In addition to
the setting up of the framework for the treatment, the first two sessions
are important in fostering the patient’s motivation to become sober. Ambivalence and denial are likely to be relevant concerns in the early phase
of treatment. Because they are so fundamental to the recovery process,
the counselor should discuss them here or at any future point in the individual patient’s treatment.
Goals
1.
Introduce the patient to the counseling program and its expectations. If the counseling will be time limited, point that out.
2.
Obtain the patient’s history. Develop a treatment plan.
3.
Help the patient to realize that he or she suffers from the disease of
addiction.
4.
Help the patient to decide to break the addictive cycle.
5.
Help the patient to see the benefits of a drug-free lifestyle.
25
Chapter 7 Treatment Initiation
Treatment Issues
Denial
1.
Denial
2.
Ambivalence
Denial is defined as refusing to believe the reality about one’s life circumstances. It may be refusing to believe that one is addicted or refusing
to acknowledge that the losses one has suffered as a result of the addiction are significant.
Patients often enter treatment with some denial about their addiction,
so this behavior should be pointed out and explored early in counseling. In spite of evidence to the contrary, addicts may believe they still
can control their chemical use. They often do not believe that they
have the disease of addiction, and they frequently are ambivalent
about giving up their drugs.
A patient experiencing denial may exhibit some of the following erroneous beliefs:
1.
Refuse to believe that he or she is an addict.
2.
Think that he or she can solve the problem by “cutting down” on cocaine use, rather than eliminating it totally. Patients may also say that
they want to get their cocaine use back “under control.”
3.
Refuse to believe that a secondary drug (alcohol, for example) is a
problem, as well as their primary drug of choice (cocaine, for example).
4.
Refuse to believe that Alcoholics Anonymous or Narcotics Anonymous will be helpful, because he or she is “not like the people there,”
ostensibly because their drug problems are so severe.
5.
Insist on continuing to spend time with “friends” who enable the patient’s use by agreeing that drugs are not a problem.
When the counselor recognizes that denial is interfering with the patient’s ability to successfully deal with the addiction, the counselor
should endeavor to get the patient to realize that he or she is not seeing
the truth about the addiction. Finally seeing the truth will foster motivation and promote a desire to change. The counselor may use confrontation, pointing out what the addiction has cost the patient, and encourage the patient to abstain from drugs temporarily if he or she truly is not
addicted.
26
Chapter 7 Treatment Initiation
Ambivalence
Patients usually enter treatment with some ambivalence about staying
sober or making a commitment to treatment. The patient’s motivation
should be examined early in the counseling sessions.
Feelings of ambivalence often are present for the following reasons:
1.
The patient associates drug use with some positive emotional
change.
2.
Drug use may have been employed as a coping strategy for solving
problems, and the patient does not yet know of a better coping
strategy.
3.
The patient may feel too weak or helpless to break the powerful cycle
of addiction.
A patient’s feelings of ambivalence should be explored so the counselor
can assist the patient to recognize the ambivalence and identify the underlying reasons. Understanding the patient’s reasons also will help the
counselor to direct discussion regarding motivation appropriately.
Motivation refers to how much the patient is impelled to act on the desire to become sober. A patient may enter treatment already somewhat
motivated because he or she recently “hit bottom” in some way. Such a
“bottom” may be losing one’s job or one’s spouse, draining one’s bank
account, or getting arrested. Although these consequential life events
may help to motivate the patient, they may not be sufficient. Additionally, the counselor should encourage and support the patient’s desire to become sober.
The counselor should discuss the patient’s ambivalence and motivation
to quit using and commit to recovery. Encouraging the patient to discuss
the pros and cons of using and focusing on the patient’s reported negative consequences of using may help to cement, or at least strengthen,
the patient’s desire to become abstinent. Having the patient identify the
personal benefits of a drug-free lifestyle, and particularly what he or she
really wants in life, helps to highlight the advantages of becoming sober.
Identifying patients’ individual goals for their life and talking about how
such goals can be attained can be empowering and lead patients to feel
more able to be proactive in making positive changes.
Introductory Sessions
Session 1
In the first session, the counselor’s goals are to establish rapport, review
the ground rules for participating in treatment, and begin to know the
patient. The patient needs to understand the expectations of the program and agree that they are important for successful treatment. Next,
27
Chapter 7 Treatment Initiation
the counselor should begin to take a detailed drug usage and treatment
history to allow the counselor to focus on the patient’s own addiction related concerns. The counselor also will want to find out recovery-related
activities in which the patient is involved (NA, religious program, etc.)
and what supports he or she has (supportive partner or family, etc.).
Session 2
The counselor should finish obtaining a thorough drug usage and treatment history that will culminate in the treatment plan, basically a contract established by the counselor and patient collaboratively. The plan
should identify the problems to be addressed in treatment and the desired goals. The primary problem identified always should be the addiction; other problems should be addiction related. In IDC, the drug-use
goal always should be total abstinence, not just abstinence from cocaine. The initial treatment plan is basic. Its purpose is to clarify the mutually agreed upon goals of the patient and counselor, with the patient
making a commitment to work toward recovery.
The counselor should inquire about the patient’s experience with
12-step groups and ask whether the patient already attends meetings, or
has previously but no longer attends, or has never heard of them. If unfamiliar with the 12-step approach, the patient should be introduced
briefly to the 12-step approach and meetings in the area. (The counselor
can provide lists of the local meetings.) All patients should be encouraged to attend meetings at least 3 to 4 times a week as part of his or her
plan for recovery. If agreed to, participation in self-help groups should
be listed on the treatment plan.
Sample Treatment Plan
Goals:
1.
Abstain from use of all illicit drugs.
2.
Attend all scheduled counseling sessions and submit to urine
drug screens as requested.
3.
Attend at least three 12-step meetings a week and speak in at
least one meeting.
Patient’s Signature ________________________________
28
Chapter 8 Early Abstinence
The second stage in treatment of addiction is early abstinence. After the
patient acknowledges the need for treatment and shows at least a preliminary commitment to treatment, the counselor and patient must begin to
work on early abstinence issues.
These include:
1.
Recognizing the medical and psychological aspects of cocaine
withdrawal.
2.
Identifying triggers to drug use and developing techniques for avoiding these triggers.
3.
Learning how to handle drug craving without using.
The counselor should encourage the patient to establish a drug-free lifestyle that involves participating in self-help groups to aid in one’s recovery, avoiding social contact with drug-using associates, and replacing
drug-related activities with healthy recreational activities. This period of
treatment lasts from the preliminary establishment of motivation toward abstinence to approximately 3 months into recovery, assuming the
patient makes reasonable progress.
The topics described here are particularly relevant to the needs of the
patient at this point in treatment. The order in which they are presented
is generally the order in which they often emerge as treatment issues.
But, the counselor should use discretion and address these issues as
they seem appropriate for each individual patient.
Discussions of these topics may be repeated as needed. The counselor
should base the relative emphasis placed on each topic on the patient’s
needs in recovery. No more than two topics should be introduced to the
patient in a session. However, in reviewing topics previously introduced, the counselor can address all appropriate topics. Although the
order in which they are presented and the relative emphasis are flexible,
all the issues identified here should be addressed in the counseling
sessions.
29
Chapter 8 Early Abstinence
Goals
1. Teach the addict to recognize and avoid the environmental triggers
that lead to drug use.
2. Teach the addict to engage in alternative behaviors when he or she
experiences craving.
3. Help the patient to achieve and sustain abstinence from all drugs.
4. Urge the patient to participate in healthy activities.
5. Encourage participation in self-help groups.
Treatment Issues
1. Addiction and the associated symptoms
2. People, places, and things
3. Structuring one’s time
4. Craving
5. High-risk situations
6. Social pressures to use
7. Compulsive sexual behavior
8. Postacute withdrawal symptoms
9. Use of other drugs
10. 12-step participation
Addiction and the
Associated Symptoms
The counselor should review with the patient the concept of addiction
and the behavioral and medical/physiological symptoms of the disease.
When discussing symptoms, the counselor should focus on cocaine but
can include other drugs as appropriate.
The concept of addiction is that the behavior, or use of something, becomes compulsive, leaving the addict no control over the behavior. Because the addict has no control over this behavior, he or she will continue to use the drug despite the resulting impairment to physical and
emotional health, social and occupational functioning, and intimate
relationships.
30
Chapter 8 Early Abstinence
The behavioral symptoms of addiction include narrowing of one’s behavioral repertoire, predominance of the drug in the person’s daily life,
spending time achieving or recovering from drug effects, and continuing to use in spite of the severe problems associated with use. The counselor will review with the patient the specific symptoms of addiction that
he or she has demonstrated. The counselor will focus primarily on the
life-overwhelming nature of addiction and the importance of avoiding
abusable substances in order to provide the best chance for preventing a
relapse.
The medical/physiological symptoms also should be reviewed with the
patient. They can include increased pulse and blood pressure, anxiety,
paranoia, hallucinations, seizures, cardiac arrhythmias, cardiac arrest,
and cerebrovascular incidents (strokes). The relative risks for each of
these adverse effects will be reviewed. For example, anxiety and paranoia are much more common than seizures or cardiac arrest. The cocaine withdrawal symptoms of depression, low energy, and insomnia
will be described, along with the fact that these symptoms do not occur
in all cases.
If the patient’s route of administration of any drug used has included injection, and/or the patient has engaged in unsafe sexual behavior, perhaps impulsively when using cocaine, then infection with the HIV virus
is a medical condition that may co-occur with cocaine addiction. The
topic of HIV infection should be introduced here. The counselor must
assess the patient’s level of knowledge and sophistication about the
topic and present information at an appropriate level. If the patient has
engaged in high-risk behavior, or the counselor believes the patient may
have engaged in high-risk behavior even though he or she denies it, then
the patient’s risk factors or potential risk factors should be identified,
and behavioral changes to reduce risk should be encouraged at this
point.
The medical effects of other abused substances, including alcohol, also
should be reviewed if the patient has or has had problems with these
drugs.
People, Places, and
Things
People, places, and things are a way of designating the external triggers
that initiate craving or the urge for a drug. The patient must learn how to
deal with these triggers in order to achieve continued abstinence. This
topic is central to addiction counseling and usually requires repeated
discussion throughout treatment. First, the counselor should help the
patient to identify the people, places, and things that will trigger or lead
to a cocaine craving or urge. Then the counselor should point out that
the patient must avoid the people, places, and things that trigger craving
and have the patient discuss how he or she can avoid the triggers. The
patient should be encouraged to avoid those triggers that are possible to
avoid easily (for example, having one’s paycheck deposited directly or
31
Chapter 8 Early Abstinence
taking public transportation to and from work rather than drive through
a risky area). The patient and counselor should collaborate to develop
strategies to help the patient avoid or manage those things that are more
difficult to stay away from (for example, a drug-using partner or spouse
or a crack house on the block where one lives).
During an individual’s addiction, he or she has learned to associate cocaine use with people, including one’s dealer or other users; places, like
a particular crack house or corner; and things, especially money and
drug paraphernalia. The counselor should strongly encourage the patient to avoid those people, places, and things that were previously associated with drug use and assist the patient in developing strategies for
avoiding these triggers. These strategies may include having someone
the addict trusts handle his or her money, cutting up his or her automatic teller machine card, getting rid of drug “works,” i.e., paraphernalia (preferably with someone else’s help); staying away from certain
neighborhoods, blocks, or areas of his or her community; and avoiding
drug-using friends and family members. Triggers that cannot be avoided
altogether can sometimes be faced more safely in the company of another, non-using person, such as one’s sponsor or one’s spouse or child.
CASE EXAMPLE
A patient, Johnnie, reports that his cohabiting girlfriend, Lisa, has a serious cocaine problem. She is smoking about $25 worth of crack every
evening if she has the money. Johnnie reports that she often borrows
money from him, and she offers him some cocaine when she buys it. He
finds it nearly impossible to resist when she is using it around him. In addition, she often asks him to drive her to purchase it because they only
have one car.
Interventions
32
1.
It appears that Johnnie’s girlfriend, Lisa, is a trigger for him. First, the
counselor should determine how serious and important this relationship is. If Johnnie says that he does not love this woman and is
not committed to staying in the relationship, then the optimal plan
may be to empower Johnnie to terminate the relationship or at least
to stop living with Lisa, so that he can make more effort toward his recovery.
2.
If Johnnie feels committed to the relationship and to living together,
the counselor should find out how amenable Lisa is to participating
in treatment. The counselor first will want to discuss this matter with
Johnnie and then possibly invite Johnnie to ask Lisa to attend a couples session. The goal should be to get Johnnie to tell Lisa that it is
important to him that she participate in his treatment, either by de-
Chapter 8 Early Abstinence
ciding to get clean and getting into treatment herself or at least by
supporting his treatment—by not bringing cocaine into their home,
using around him, asking him to get high with her, or asking him for
money or for a ride to pick up the cocaine. If she agrees to either option, that is a positive sign. The counselor also will want to help Johnnie be assertive about not lending Lisa money, or giving her rides to
where she buys drugs, and perhaps about holding her to her commitment, whatever it is.
Structuring One’s
Time
3.
The counselor will want to discuss Johnnie’s sexual relationship
with Lisa. First, does sex with her always involve cocaine use? Do they
have good sexual experiences without using cocaine? Obviously, if
sex typically involves cocaine use, this unhealthy situation must be
discussed in depth. The goal then would be to get Johnnie to recognize the danger of the situation and to try to abstain from drug use
when having sex. If that is not possible, then the counselor should
advise Johnnie to abstain from sexual experiences temporarily until
he has established some abstinence from cocaine. Also, the counselor should find out whether the couple practice safe sex and generally what they do or have done to minimize their risk of HIV exposure
via sexual transmission. Depending on the answer, the counselor
may want to teach Johnnie about safer sexual practices.
4.
Lastly, the counselor may help Johnnie to identify healthy leisure activities that he and his girlfriend might enjoy together without using
cocaine. These could include going to movies or sports events, taking walks, or going shopping.
If the patient has a chaotic, disorganized lifestyle, the counselor will
help the patient to identify what he or she does each day and help to
structure his or her days to encourage abstinence. People with drug-use
disorders often live in an impulsive and chaotic manner. Order and
structure can help to lessen the risk of relapse. One of the defining features of drug addiction is the priority that the drug assumes in the individual’s daily existence. Many addicts organize their entire daily routine
around obtaining, administering, and recovering from the effects of
their drug(s). Because of the time these behaviors require, many people
with a drug-use disorder experience a void, or a sense of loss, shortly after stopping the drug. They have spent so much time working for drugs
and associating with people, places, and things associated with taking
drugs that they have difficulty imagining what to do when they are not
using drugs.
The counselor must try to counteract this lifestyle, as well as restructure
the content of the addict’s daily activity, by trying to help organize the
patient’s daily routine. One way to help the patient achieve a better organizational pattern is to work out a daily schedule for the week, or until
the next session, and to review it. Structuring one’s time is an important
33
Chapter 8 Early Abstinence
aid to recovery, because having definite plans and staying busy helps the
recovering addict not to have excess free time, which is all too likely to
be spent thinking about using drugs. When newly recovering addicts
have too much free time, they are likely to recall the “good times” they
had using their drugs. This experience is called “euphoric memory” and
understandably tends to lead to desire for the drug.
Also, a structured life helps the patient to reduce residual physical symptoms from the cocaine use and to decrease negative emotional effects,
such as depression or boredom. The counselor will discuss how the patient spends his or her time and help the patient structure the time to
support abstinence. This structure should include getting up each
morning and going to bed at night at regular times, scheduling time for
12-step meetings at least 3 to 4 times a week, and including time for handling personal responsibilities and engaging in healthy recreational activities.
Sample
Schedules
Following are two sample schedules. The counselor can choose whichever one is more suitable for the patient’s lifestyle and needs. A schedule
form can be given for the patient to complete as homework prior to the
session, or the patient and counselor can complete a schedule together
and simultaneously discuss it during the session.
Planning a daily schedule together is helpful when the patient’s life is
very chaotic or organized primarily
around the drug addiction. With a
Danny’s Daily Schedule
daily schedule, the counselor and
7 am Wake up, get dressed
patient can look at the patient’s day
and identify the patient’s danger8
Walk dog
ous times and plan healthy activities
9
Counseling
to fill those times. The counselor
10
NA meeting
also should remember to support
and encourage anything the patient
11
Return home
is doing that is positive, such as atNoon Lunch
tending 12-step meetings, taking
1 pm
care of his or her dog and getting
2
some exercise, attending counseling regularly. The issue of bore3
dom, which is a common trigger for
4
patients, can be addressed at this
5
time, and ways to keep busy in or6
der to reduce boredom can be encouraged.
7
8
Watch TV or go out
Danny is unemployed, and his life is
9
very disorganized. The counselor
10
and Danny have been working on
getting him to attend his counseling
11
Turn in if at home
sessions regularly, two mornings a
34
Chapter 8 Early Abstinence
week, and to attend an NA meeting every day. This approach is helping
Danny begin his day at a consistent time every morning. From the schedule, obviously Danny has too many empty hours in the afternoon and
evening, and boredom is likely to be a problem. Now the counselor and
Danny need to plan how he can fill some of these hours, perhaps by
working out, visiting a nondrug-using family member, going to school,
working part time or doing volunteer work, going to a second 12-step
meeting, or spending time with recovering peers.
Preparing a weekly schedule is helpful for the patient who has some
structure in his or her life, perhaps a job, but who has a particular time
that is very dangerous or a trigger for her. In Elaine’s case, she is pretty
responsible during the week, but Friday night through Sunday afternoon is a dangerous period for her, because her children’s father (they
are separated) takes the children. Also, Elaine feels stressed and burdened by the responsibilities of her week, and she needs to do something to relax and pamper herself over the weekend. Unfortunately,
many people turn to drug use to “nurture” themselves when they feel
very stressed by their daily life, because it is such a “quick fix” even
though it ultimately causes them to feel more stressed and unhappy.
Elaine’s Weekly Schedule
Monday
Tuesday
Wednesday
Thursday
Friday
7 am
Get up
7 am
Get up
7 am
Get up
7 am
Get up
7 am
Get up
9–2 work
9–2 work
12 noon
NA meeting
Saturday
Sunday
9–2 Work
12 noon
NA meeting
3 pm Pick
up kids
3 pm Pick
up kids
3 pm Pick
up kids
3 pm Pick
up kids
Free time
3 pm Pick
up kids
4–9 Make
dinner,
spend time
with kids
4–9 Make
dinner,
spend time
with kids
4–9 Make
dinner,
spend time
with kids
4–9 Make
dinner,
spend time
with kids
Kids are
with
their father
4–9 Make
dinner,
spend time
with kids
11:30
Turn in
11:30
Turn in
11:30
Turn in
11:30
Turn in
11:30
Turn in
35
Chapter 8 Early Abstinence
In this situation, the counselor probably wants to acknowledge that
Elaine handles a lot of responsibilities well during the week and has little
time for herself. Then the counselor can discuss with Elaine how she
feels about her free time over the weekend and what she can do to avoid
drug use during this time. They can problem solve to identify things that
she can do to take care of herself during her free time over the weekends. Possibilities include joining a bicycling club, taking a dance class,
reading a good book, having her nails or hair done, or visiting a recovering friend or a family member.
Preparing a weekly schedule also is helpful if a patient in recovery seems
to be overscheduling himself or herself and cannot fit in a needed additional 12-step meeting or some personal time to relax. If a recovering patient seems to be overzealous and compulsive about keeping busy as a
way to stay clean, a weekly schedule can be a way to illustrate and discuss
this tendency.
Craving
The counselor should discuss the concept of craving with the patient.
Craving is the strong desire an addict experiences for his or her drug of
choice, such as cocaine. Some patients may not identify with the word
craving but instead may use the word urge. Individuals appear to experience craving differently, but they usually describe physical and psychological symptoms. In the case of cocaine, these symptoms include heart
palpitations, rapid breathing, obsessional thinking about the drug, and
planning how one can get the drug or get the money needed to buy it.
Craving is thought to be due in part to biological factors and in part to
learning. Probably all cocaine addicts experience craving for cocaine.
The counselor must help the patient to understand and recognize what
craving or having an urge feels like. Recognizing craving will help the patient to maintain abstinence. The counselor should communicate to the
patient that he or she can experience and recognize a craving but choose
not to act on it in the usual, self-damaging way. Craving, however strong,
does not have to lead to drug use. One can just “sit the craving out,” and
it will pass. A useful analogy may be likening the craving to a strong
ocean wave. The wave will feel very strong when one is in the throes of it,
but it will wash over and pass. Also helpful is explaining that the strength
of cravings will decrease over time if the patient does not use, but if he or
she uses the drug, the craving phenomena will remain strong.
High-Risk Situations
36
High-risk situations are those times that involve the people, places, and
things that trigger the addict’s cocaine craving. The counselor should
discuss situational triggers with the patient and help the patient to avoid
them if possible or learn to cope by developing the alternative responses
necessary to deal with these situations without using. This topic should
be largely a review of what the patient has learned about people, places,
and things in general but with an emphasis on the actual situations that
Chapter 8 Early Abstinence
recur in the patient’s own life and trigger a craving for cocaine. Learning
how to avoid these times or to develop alternative responses to whatever triggers the desire for cocaine is central to recovery from addiction
and bears regular repeating. The counselor will review with the patient
actual and potential “high-risk” situations that might occur and what can
be done to avoid them. Examples of high-risk situations are being offered drugs, being around a drug-using friend, or attending a social
function where drugs are available. The counselor should rehearse with
the patient alternative responses to exposure to these situations. Identifying such situations well in advance and rehearsing how one could
deal with such exposure should provide a better chance of avoiding a relapse from such exposure.
After the patient identifies his or her particular high-risk situations, the
counselor and patient should work together to develop strategies for
avoiding these situations. Other potential high-risk situations also
should be considered. The counselor should offer reasonable alternative responses to unavoidable high-risk situations, such as calling a
friend or talking to one’s partner or spouse. The patient should be encouraged to use the support of drug-free or recovering friends, family
members, and AA/NA/CA acquaintances.
Social Pressures
To Use
Many addicts report that their entire social life revolves around their addiction. Addiction limits the scope of their social interactions to the
point where all of their social contacts are with other addicts, usually
creating a lot of social pressure to use in order to remain within the
group. Addicts have to face this social pressure. Other addicts might not
want the addict to recover, because they are reminded of the failings and
liabilities of their own illness. They will put pressure on the addict who
is trying to break the cycle of addiction. This pressure may be blatant,
such as offering the recovering addict drugs or demeaning him or her for
trying to recover. Alternatively, they may use more subtle techniques,
such as mentioning previous “good times” involving drug use.
The counselor should ask the patient if he or she feels pressured by
peers to continue or resume using drugs. If so, the patient’s peer group,
the experience of the pressure, and the patient’s response to the pressure should be discussed.
The simplest resolution to this problem—the avoidance of all drug users—should be strongly encouraged. Recovering addicts who are feeling more dependent and greatly need to fill the void left by the drugs
may be lonely. The patient needs to realize that the people with whom
he or she was getting high were not true friends and begin to forge positive relationships with drug-free and recovering people. Participation in
AA, NA, or CA should be encouraged as a way of filling the void left by the
loss of drug-using peers. Establishing a new, recovering peer group
37
Chapter 8 Early Abstinence
within the 12-step program creates positive social pressure to remain
abstinent that often is very helpful.
Compulsive Sexual
Behavior
Frequently, sexual encounters become associated with the use of cocaine, because many people believe that cocaine enhances sexual experience. In actuality, cocaine distorts the sexual experience so that it
eventually becomes an emotionally painful, compulsive quest to get the
best high or rush similar to the experience of using cocaine.
Many cocaine addicts have a problem with compulsive sexual behavior,
which should be addressed at various points in the addiction treatment.
In early abstinence, the first issue to address is whether sex or the potential for sex is a trigger for the addict. If the patient’s craving for cocaine or
any drug is triggered by sex, the counselor needs to encourage the patient to avoid those sexual stimuli that trigger craving. The counselor
should explore with the patient the sexual situations that lead to craving, as well. For example, the patient may prostitute to get drugs or meet
with a prostitute to get sex in exchange for drugs. Also, a patient may be
aroused by sexual experiences involving pornography or sexual paraphernalia, along with the use of cocaine. The patient needs to avoid such
triggers, and the counselor should help the patient to identify healthy alternative ways to fulfill appropriate sexual desires.
For some patients, the message in the beginning of treatment can be to
avoid sexual stimuli for a while. Later, when the patient is more stable,
the counselor and patient can work on establishing healthier means of
sexual expression for the patient. For other patients, asking them to abstain from sexual behavior for a while is not practical. In these cases, the
counselor and patient must ascertain what types of sexual behaviors are
emotionally affirming rather than compulsive. The patient should be encouraged to participate only in these more positive kinds of sexual experiences.
If the patient has participated in impulsive or promiscuous sexual behavior, information about HIV infection, safe sex practices, and the patient’s risk factors should be addressed.
Postacute Withdrawal Some people, particularly those who have used cocaine in large
amounts over long periods of time, will experience long-lasting changes
Symptoms
in mood, affect, and memory. These changes may continue for days or
weeks after the cocaine use has been stopped. Anxiety and/or depression, often accompanied by difficulty in sleeping, are some of the symptoms that may occur. Other patients experience panic attacks that persist for varying time periods after episodes of cocaine use. Some complain of difficulties in short-term memory, such as alcoholics experience
after detoxification. Another problem is feelings of anhedonia or lack of
pleasure in life; the addict experiences depression or other symptoms of
38
Chapter 8 Early Abstinence
a mood disorder that can persist beyond the period of acute detoxification. These symptoms are known as postacute withdrawal symptoms
(Gawin and Kleber 1986).
Other patients with cocaine addiction do not have any of these symptoms after stopping drug use. Those who have the symptoms usually experience them for a relatively short time. The drug counselor must be
aware of the symptoms of postacute withdrawal and discuss them with
the patient. The aim is to help the patient identify them if they occur and
to label them appropriately as symptoms that have resulted from cocaine use. The danger is that the patient will interpret the symptoms as
being fundamental problems with himself or herself that can be reversed or corrected by self-administration of cocaine or other drugs. The
counselor is to be very firm in telling the patient that such symptoms are
most likely a result of drug use rather than an independent disorder and
that they will be, in fact, made worse, not better, if cocaine is used.
Use of Other Drugs
Frequently patients see themselves as being addicted only to their drug
of choice in spite of the fact that they frequently use another drug or
drugs as well. For example, if the individual is in treatment for cocaine
addiction, he or she may believe that alcohol or marijuana still can be
used nonaddictively. The counselor should strongly encourage the patient to accept the necessity, if he or she is to achieve full recovery, for total abstinence from all drugs (excluding, of course, any appropriately
prescribed medications).
The counselor must first find out what, if any, mood-altering substances
the patient is continuing to use. If the patient denies use of any
mood-altering substances, this topic should still be addressed briefly before discussing other issues. If the patient continues to drink alcohol or
use another drug, the counselor should engage the patient in a discussion of the pros and cons of continuing to use these drugs.
The counselor should also point out the following reasons for total abstinence:
1.
Other drugs, such as alcohol, are likely to trigger a craving for cocaine.
2.
An addict may transfer the addiction to the other drug and begin using it compulsively.
3.
An individual who uses alcohol or marijuana, for example, will not
learn how to cope with daily stressors, relax, or have fun without the
use of mood-altering substances.
If the patient is particularly resistant to giving up use of his or her secondary drug(s) on a permanent basis, the counselor may be more suc39
Chapter 8 Early Abstinence
cessful by avoiding the power struggle and encouraging the patient to
abstain temporarily (for the length of the time that he or she is in treatment), rather than directly confront the resistance. This issue then will
reemerge at a later point in treatment, giving the counselor and patient
another opportunity to discuss the importance of abstaining from all
mood-altering substances to achieve recovery.
CASE EXAMPLE
Bill likes to go to the local bar for a couple of beers and to play darts after
work sometimes. He says that the beer never gets him into trouble;
rather, he only has a problem with cocaine. He enjoys socializing at the
neighborhood bar and typically only has a couple of beers and then goes
home to his wife. However, after pressing Bill, the counselor finds out
that when Bill gets cocaine, he gets it from a contact at the bar. It is usually on the weekends, when he typically drinks more heavily than he
does on the weeknights, and then he meets up with his contact and they
go and buy cocaine. Bill is primarily a binge user, and in these binges, he
often spends $500 in an evening, a habit he cannot afford.
Interventions
40
1.
This behavior is an example of denial. The counselor wants to help
Bill to see the link between the alcohol and the cocaine. One approach would be to confront the patient gently. The counselor
might say, “Well, it sounds like you don’t go and pick up cocaine until after you have had a few drinks at the bar. So, even though your
drinking doesn’t always lead you to pick up, in the instances (or at
least most of the instances) when you do pick up, you have been
drinking first.” Amazingly, patients often have never recognized this
connection.
2.
The counselor might try to persuade Bill of the seriousness of this
problem by having a conversation about the magnitude of the financial difficulties he is getting himself into because of his cocaine use.
3.
The counselor’s aim is to get Bill to change these damaging behaviors. The optimal change would be if Bill can agree not to go to the
bar and not to drink alcohol in addition to not using cocaine. If Bill
cannot imagine himself relinquishing this social outlet, a compromise might be that he could drink soda instead of beer while he is socializing, never carry more than $10 in his pocket, and not go to the
bar on weekends. If this type of compromise is established, which is
not ideal, the counselor must keep abreast of Bill’s progress with this
and press him to avoid the bar and abstain from all drugs if this compromise plan does not work.
4.
Bill might respond to the recommendation that he carry less money
by saying that he does not need money in his pocket, because he can
Chapter 8 Early Abstinence
get cocaine on credit. The counselor would concede this truth but
remark that by choosing not to carry much cash, Bill is making it
harder for himself to buy cocaine and easier for himself to resist. Not
having the money right there will serve as a reminder that he has decided not to use (if indeed he has) and might just give Bill the extra
incentive he needs to leave the bar without picking up. If Bill has difficulty not carrying money because having money is closely associated with his sense of self-worth, then the counselor must be sensitive and really compliment Bill on taking a proactive approach to his
recovery by not carrying extra cash.
5.
12-Step Participation
The counselor also will want to check into the status of Bill’s relationship. Is he spending time at the bar because of marital discord? If
he denies that and says his marriage is strong but hanging out at the
bar is what the men in his neighborhood do, then the counselor will
want to encourage him to make specific plans to spend quality time
with his wife in place of going to the bar. If, on the other hand, his
marriage is strained, the counselor will want to determine whether
marital discord triggers Bill’s cocaine use and will want to point out
that link.
All patients who are treated for addiction are advised to participate in
one or more self-help groups. The most popular self-help groups are the
12-step groups, including Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA). The addiction counselor
must be familiar with the general 12-step philosophy and the 12 steps
and be able to review them, and the principles involved, with each patient. Reviewing these concepts will serve to familiarize the patient with
the 12 steps in a very general way and help the patient to apply the
12-step approach to specific aspects of his or her recovery program.
As the patient attends counseling sessions, the counselor will want to
monitor the patient’s participation in self-help groups. The counselor
should inquire about the patient’s participation in, and thoughts and
feelings about, 12-step groups and follow up by providing whatever further information or encouragement the patient needs about self-help
groups and the 12-step philosophy; for example, giving patients a current meeting list for their neighborhood or describing where the local
NA clubhouse is. Also, if the patient expresses some hesitancy about attending meetings because of the people, the counselor might assess
what kind of people the patient would be likely to be most comfortable
with and recommend that type of meeting. The counselor should explain to the patient that there are gay and lesbian meetings, women’s
meetings, nonsmoking meetings, medical professionals meetings, and
so forth.
Once the patient is attending 12-step meetings, sponsorship should be
discussed and encouraged. The role of a sponsor is to be a guide and a
41
Chapter 8 Early Abstinence
support person for the recovering addict. The sponsor will take a special
interest in the addict’s recovery and will draw from his or her own experiences in recovery and personal relationship with the 12-step program
to aid the addict in recovery. The patient should select a sponsor from
among the more advanced recovering individuals he or she has met in
the group. The sponsor should be someone who is working through the
program in a healthy way, has the patient’s respect, and has something
to offer the patient emotionally toward personal recovery. Also, if the patient is heterosexual, the sponsor should be the same gender to avoid
the complication of sexual attraction and the potential for sexual acting
out between sponsors and sponsees. Important to the patient’s recovery
is feeling that he or she can have an intimate relationship with the sponsor and that this relationship does not become sexualized. No specific
parallel rule applies if the patient is gay or lesbian; however, the principle remains the same. Recovery must not sexualize the sponsor-sponsee
relationship.
In reviewing the 12-step program, the counselor should emphasize the
importance of participating in self-help groups and also make the patient comfortable with the 12-step process, including sponsorship. Discussions about the 12-step program also will serve to introduce the idea
of continuous, even lifelong participation in a personal recovery
program.
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Chapter 9 Maintaining Abstinence
The next stage of recovery is maintaining abstinence. The addict who has
achieved abstinence now works toward continuing the abstinent behavior—avoiding environmental triggers, recognizing his or her own
psychosocial and emotional triggers, and developing healthy behaviors to
handle life’s stresses. The patient now “practices” the drug-free lifestyle
begun in the previous stage of recovery. One of the key factors in preventing relapse to drug use is maintaining a recovery-oriented attitude by retaining a humble attitude toward the power of the addiction and not taking one’s abstinence for granted. Personal vigilance against relapse is paramount. Vitally important are continued participation in self-help groups
and honesty about feelings and thoughts that could lead one to a relapse.
Ideally, this stage of treatment begins at about the fourth month of treatment, assuming the patient has achieved preliminary abstinence in the
previous stage of treatment. The topics described here are particularly
relevant to the needs of the patient at this point in the recovery process.
The order in which they are presented is generally the order in which
they often emerge as treatment issues, but the counselor should use discretion and address these issues as they seem to be most relevant for the
individual patient.
The counselor may repeat discussions of these topics as needed. The relative emphasis placed on each topic is based on the patient’s individual
needs in recovery. To avoid confusion, and to avoid overload, no more
than two topics should be introduced to the patient in a session. However, in reviewing topics previously introduced, the counselor can address as many topics as relevant. While all the issues identified here must
be addressed in the counseling sessions, the order in which they are presented, and the degree of relative emphasis, is flexible.
Goals
1.
Help the patient continue to maintain abstinence.
2.
Make the patient aware of the relapse process, so it can be avoided or
reversed quickly.
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Chapter 9 Maintaining Abstinence
3. Assist the addict in recognizing emotional triggers.
4. Teach the patient appropriate coping skills to handle life stresses
without returning to drug use.
5. Provide the opportunity for the patient to practice newly developed
coping skills.
6. Keep encouraging the behavior and attitude changes necessary to
make sobriety a lifestyle.
Treatment Issues
1. Tools for preventing relapse
2. Identification of the relapse process
3. Relationships in recovery
4. Development of a drug-free lifestyle
5. Spirituality
6. Shame and guilt
7. Personal inventory
8. Character defects
9. Identification and fulfillment of needs
10. Management of anger
11. Relaxation and leisure time
12. Employment and management of money
13. Transfer of addictive behaviors
Tools for Preventing
Relapse
Relapse prevention is an extremely important component of recovery.
After the patient has established some stability in abstinence, he or she
should start to develop skills to prevent future relapse to drug use. The
patient must learn how to manage negative or uncomfortable feelings
without using cocaine or other drugs.
Relapse prevention involves teaching the patient to recognize in
advance when he or she is headed toward a relapse and to change
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Chapter 9 Maintaining Abstinence
direction. A relapse does not begin when the addict picks up the drug—
it is a process that begins before actual use. With education, the patient
easily can recognize markers indicating imminent relapse. Indeed, the
recovering patient must become aware of these markers. Identified in
greater detail in the next topic section, these markers can most simply be
described as negative changes in attitudes, feelings, and behaviors.
Usually, patients can recognize examples of these negative changes in
their own lives and, thus, develop an understanding of the relapse process. Once the patient becomes aware of the nature of the relapse process, the next task is to develop the ability to intervene and change any
negative feelings or risky behaviors which occur. A relapse is caused by
failure to follow one’s recovery program. The task for the counselor and
patient is to identify early those situations where the patient is starting to
deviate from a healthy recovery plan and work to curtail and prevent the
deviation.
In advance of any relapse there is a need to set up concrete, behavioral
changes that the patient will need to make to get out of a relapse process
and return to a healthy recovery program. Such behavioral changes may
include going to meetings more frequently, spending time with people
who support recovery, maintaining structure in his or her lives, and
avoiding external triggers, such as going back to the neighborhood
where he or she obtained drugs.
Identification of the
Relapse Process
How to recognize relapse warning signs or the relapse process is usually
a very helpful skill to teach the patient and one that bears repeating.
Relapse is a common event following detoxification and can occur at any
time during recovery. Because relapse is a common, complex, and difficult occurrence, the addiction counselor should educate the patient
about the process of change associated with impending relapse. Particularly important is the recognition of the signals, events, or situations in
which the risk is especially high, so the patient sees the process of relapse for what it is and avoids it.
As described below, Gorski and Miller (1982) identified 11 steps that
will carry a patient toward a relapse. Teaching the patient the process is
not necessary if he or she can grasp more easily the simpler “changes in
attitudes, feelings, and behaviors.” The information presented below
should give the counselor a more complete understanding. The concepts should be presented to the patient in whatever way he or she can
best understand and use them.
Gorski and Miller’s steps are:
1. A change in attitude in which the patient no longer feels participating in the recovery program is necessary or a change in the daily routine or life situation that signals a potentially stressful life event.
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Chapter 9 Maintaining Abstinence
2. Elevated stress, as seen by overreactivity to life events.
3. Reactivation of denial, particularly as related to stress, as seen when
the patient is stressed but refuses to talk about it or denies its existence. This behavior is of great concern because of its similarity to denial of drug addiction or abuse.
4. A recurrence of postacute withdrawal symptoms, which are especially likely to occur at times of stress. They are dangerous because
the patient may turn toward drugs or alcohol for relief.
5. Behavior change. The patient begins to act differently, often after a
period of stress, as signaled by a change in attitude or daily routine.
6. Social breakdown. The social structure the patient has developed
begins to change. For example, she no longer meets with her sober
friends, or he becomes seclusive and withdrawn from his family.
7. Loss of structure. The daily routine that the patient has constructed
in the recovery program is altered. For example, he sleeps too late,
skips meals, or does not shave.
8. Loss of judgment. The patient has difficulty making decisions or
makes decisions that are very unwise. There may be signs of emotional numbing or overreactivity.
9. Loss of control. The patient begins to make irrational choices and is
unable to interrupt or alter them.
10. Loss of options. The patient feels stressed and believes that the only
choices are to resume drug use or to undergo extreme emotional or
physical collapse.
11. Relapse in which substance use is resumed.
The addiction counselor should become familiar with these signs and
review them with the patient so the patient can watch for these signals.
The counselor also should observe the patient closely for any evidence
that these signs are occurring. If they appear, the counselor should
point them out and help the patient address and reverse them. Reversing the process leading to relapse always involves recommitting
oneself to one’s recovery program by increasing attendance at 12-step
meetings, changing one’s living situation to a drug-free environment, or
taking positive action to resolve relationship, personal, or work-related
problems. The aim of the counselor is to help the patient return to a relaxed, organized, and symptom-free lifestyle; that is, one which is most
suitable, given the real constraints, for continuing recovery.
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Chapter 9 Maintaining Abstinence
CASE EXAMPLE
Sandy now has 3 1 2 months clean. If you were to ask her, she would tell
you she has 110 days, today. She is feeling really good about this, so
good in fact that she feels ready to return to work, which the counselor
supports. She is employed as a server in an exclusive restaurant, and her
bosses are pleased to give her the job back, because she is an excellent
worker. Soon she becomes quite busy at work, taking on extra shifts to
make additional, much-needed money, and she cuts back on her NA
meeting attendance. The daily structure she established in recovery is
dissolving. Because she is working late hours, she is sleeping late in the
morning, not eating regular meals, and not going to her health club,
which she enjoyed. The counselor becomes worried that Sandy has entered a relapse process and is on her way to picking back up. Sandy denies this behavior (which is the typical response) and tries to justify her
changed behavior by how important the job and the extra money are to
her now.
Interventions
1.
The counselor will want to teach Sandy about the relapse process,
pointing out that the process begins long before the person picks up
and identifying those steps toward relapse that are relevant for
Sandy. In her case, the signs are a change in attitude (in that she no
longer prioritizes to attend as many NA meetings), elevated stress
(because she is overworking), reactivation of denial (because she
does not recognize the dangers of this new behavior pattern), behavior change (initiated by the return to work but progressing to include going out with work colleagues after hours), and loss of structure (because she is now going to bed late, getting up late, missing
meals, and not working out at her health club).
2.
The counselor’s main intention here will be to break through the denial and get Sandy to see that she is heading down an unhealthy path
likely to lead to a relapse. The next step will be to get Sandy to recommit to her recovery program by reinstituting her positive behaviors.
The counselor should try to get Sandy to at least reinstate some
healthier behaviors, such as attending at least three NA meetings a
week, only working a certain amount of overtime, and making time
for herself to socialize with recovering peers.
3.
If Sandy is resistant to accepting that she has entered a relapse process, the counselor may encourage Sandy to get feedback from her
sponsor or people who are in more advanced recovery. Sandy also
can be encouraged to learn from the mistakes of others. She may
know of peers who have had similar relapse processes in their recovery. The counselor can use this story to illustrate Sandy’s path.
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Chapter 9 Maintaining Abstinence
Relationships in
Recovery
Typically when addicts are active in their addiction, their primary relationship is to the drug. The chemically addicted person’s behavioral repertoire narrows, because the person spends so much of his or her time in
drug-related activities. Time and energy are spent on getting money to
buy the drug, obtaining the drug, using the drug, and coming down
from the drug. Because of this narrow focus, addicts tend to neglect
their relationships with nondrug-using people, and eventually some addicts do not even have relationships with sober individuals.
Positive, healthy relationships are an extremely important source of support during an addict’s process of recovery. The counselor should discuss with the patient his or her relationships and find out the nature of
these relationships. The counselor will want to determine whether the
patient has any positive family or social relationships that can be called
upon to provide support during the patient’s recovery. The counselor
also will be looking at whether the patient has many damaging or unhealthy relationships that will tend to hold him or her in the addiction.
Through discussion, the counselor can help the patient to identify unhealthy relationships and work toward changing his or her involvement
in these relationships.
Two types of unhealthy behavior, codependency and enabling behavior,
can contribute to a person’s continued abuse of drugs. The counselor
also should define enabling behavior and codependence and point out
such relationships in the patient’s life.
n
Codependency occurs when another individual, perhaps the addict’s spouse or family member, is controlled by the addict’s addictive behavior. Codependents become codependent because they
have learned to believe that love, acceptance, security, and approval are contingent upon taking care of the addict in the way the
addict wishes. In their decisionmaking process, they allow the addict to define reality. Unfortunately, this excessively caregiving behavior tends to foster even more dependency on the part of the
addict. Some codependents are adult children of alcoholics or addicts and their codependent behavior is the result of growing up in
the environment of addiction.
n
Enabling behavior occurs when another person, often a codependent, helps or encourages the addict to continue using
drugs, either directly or indirectly. Examples of individuals involved in enabling behavior are a spouse hiding the addict’s disease
from neighbors or their children by lying for the addict and a
so-called “friend” giving the addict money to buy drugs.
The counselor also will assist the patient to identify positive relationships with recovering or nondrug-using people who will be supportive
of recovery. The counselor should encourage the patient to call upon
these individuals for social support. If the recovering addict has no
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supportive relationships, he or she should be advised to use involvement in the fellowship in NA, CA, or AA to begin to establish supportive
relationships. Other positive social involvement should be encouraged,
such as with one’s religious organization or with a recreational organization.
CASE EXAMPLE
Johnnie, the patient we met earlier, is very ambivalent about his relationship with his cohabiting girlfriend, Lisa. He tells the counselor repeatedly that he does not love Lisa, and that they are living together mainly
because she had nowhere else to go. The problem is that Johnnie wants
sobriety, and Lisa is not ready to commit to recovery. She continues to
use cocaine around him in spite of his explaining that he wants to get sober and his asking for her support. However, he has not been able to follow through on what he and the counselor agreed: to separate from Lisa.
On a more positive note, Johnnie has been able to establish and maintain abstinence for 2 months now, and he really wants to continue working toward recovery. Johnnie says that his difficulty in breaking up with
Lisa is because she needs him so much. He says that she depends upon
him financially and for company and affection.
Interventions
1.
The counselor wants to point out that Johnnie is being codependent
and enabling here, and in so doing he is tacitly supporting or encouraging Lisa’s dependency on the cocaine and on him. First the counselor will introduce Johnnie to these concepts and discuss them.
Johnnie is being enabling when he gives Lisa money to buy drugs or
otherwise makes it easier for her to obtain them. Codependent behavior is evident in the way Johnnie cannot separate himself from
Lisa and cannot insist that she not use cocaine around him.
2.
The counselor should explore with Johnnie how his codependent
and enabling behaviors affect his recovery. The obvious conclusion
would be that these behaviors are undermining his recovery and
may potentiate a relapse. The counselor may need to point out how
they could potentiate a relapse and look at what the “cost” of relapsing would be for Johnnie at this point, since he has achieved some
abstinence.
3.
Johnnie may find it helpful to discuss what his codependent and enabling behaviors are really doing to Lisa: promoting her addiction
and in turn damaging her rather than helping her, regardless of what
she thinks at the time. Johnnie should think about what his real motivation is concerning Lisa, and what he really wants for her and for
them as a couple.
4.
The counselor should identify concrete steps for Johnnie not to take
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Chapter 9 Maintaining Abstinence
in the codependent and enabling behaviors and then support and
encourage Johnnie in taking these steps. Such steps might be to consistently be assertive with Lisa about not wanting her to use or bring
cocaine around him or to discuss with Lisa that he wants to separate,
and then talk with her to establish a specific plan for doing so.
5.
Development of a
Drug-Free Lifestyle
The counselor should strongly encourage Johnnie to talk about this
situation in his 12-step meetings and perhaps begin to attend a
Codependents Anonymous (CoDA) meeting if he does not find the
resources he needs in his own 12-step meetings. Johnnie must get
the support of others who have had similar experiences in handling
this problem, and CoDA meetings or any 12-step meetings are probably the best resource.
Recovery is a lifelong process that requires the development of a
drug-free lifestyle, one of the most important objectives of treatment.
Addicts’ entire lives often are centered on several behaviors: getting
drugs, using drugs, and associating with others who use drugs. When addicts stop drug use, they often must establish new friendships, new social patterns, and new leisure activities.
If the patient has drug-free, supportive friends and family, he or she
should be encouraged to develop these relationships and perhaps participate in recreational activities with these people. If the patient reports
having no drug-free friends or family to whom he or she can turn, then
the patient should be encouraged to make new friends, which often only
can be done slowly—by becoming involved in new social groups, such
as religious, community, or other volunteer services.
Another part of developing a drug-free lifestyle is to establish a daily
schedule that one follows in a reasonably consistent manner. Daily
scheduling, and its advantages, should have been addressed earlier in
treatment and can be reviewed here. The counselor should find out how
well the patient can structure his or her life in a manner that supports abstinence and adhere to that structure. Reviewing the patient’s daily
schedule reinforces this structure and gives the counselor the opportunity to discuss with the patient deviations from the schedule. These deviations may involve “slips” or other emerging problems; thus looking at
them in counseling often is helpful in continuing to guide the patient
toward recovery.
If patients have achieved some healthy structure in their lives, the next
component of developing a drug-free lifestyle is identifying larger goals.
While remembering that sobriety is maintained “one day at a time,” at
this point in their recovery individuals may be ready to think about what
they want in their life in conjunction with recovery, such as going back to
school, changing careers, or saving to buy a house. The counselor and
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Chapter 9 Maintaining Abstinence
patient can examine how to work toward these goals within the context
of the recovering lifestyle.
Spirituality
Spirituality, or healing the self, is an aspect of recovery related to the
12-step process but merits a separate discussion because of its importance in a successful recovery program. Spirituality is meant here in the
general sense of one’s having values and altruistic goals in life, rather
than in any specific religious sense. Patients are encouraged to relate to
a power that is transcendent and greater than they are. This “higher
power” is defined by the patient rather than the counselor and involves
connecting to a power that extends beyond the daily concerns of living.
One outlet for the expression of a connection to something greater
than oneself is found in participating in 12-step meetings, particularly
in doing volunteer service at them. Other opportunities to experience
and express this connection might lead to the patient becoming more
involved in his or her religion, in community affairs, or in charity work.
In either case, the patient is encouraged to reach beyond himself or herself as a way to find fulfillment and happiness. This experience of spirituality is a central part of participation in the 12-step groups. The addiction counselor’s role is to introduce and emphasize the idea and encourage the patient to follow through by his or her own efforts and by the fellowship of the self-help group(s) in which he or she becomes involved.
Shame and Guilt
Addiction invariably produces feelings of shame and guilt that damage
the addict’s self-esteem. Shame and guilt are both negative feelings related to the experience of addiction, but shame differs from guilt in the
following way: Shame refers to negative beliefs about oneself; for example, one is a weak, worthless, or deficient person. Guilt refers to the belief that one has engaged in wrongful behavior, such as stealing to obtain
money for drugs. Because shame is about oneself and guilt is about
one’s behavior, feelings of shame are more profoundly damaging to the
self and more difficult to heal.
Addicts usually experience feelings of both shame and guilt over their
behavior even while in their active addiction. Individuals often feel
ashamed of themselves for becoming addicted and may not feel worthy
or deserving of recovery. They may have engaged in guilt-producing behaviors that are illegal and/or immoral, such as theft or prostitution to
get money for drugs. They may feel that they have emotionally injured
family and friends. They may have regrets about what they have lost,
such as their job, home, or family. If the addict feels ashamed or guilty,
continued addictive behavior may help the person escape temporarily
from these bad feelings. It also may serve as a way for addicts to hurt or
punish themselves. An addictive disease can become a downward spiral
in which the addict gets high to escape the pain that is the consequence
of getting high.
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The counselor should help the patient to identify and talk about any
feelings of shame and guilt. The counselor will want to show the addict
how the addictive behavior is not a true relief but actually contributes to
these painful feelings about oneself. Healthy, responsible living should
be encouraged as the way of restoring self-esteem and self- respect.
Counselors should point out that being a responsible spouse, employee, friend, or family member can promote improved self- esteem.
Making amends, or apologizing, to people one has wronged in one’s addiction is another way to restore self-esteem and self-respect. This apologizing can be done, if the patient so desires, whenever it is feasible and
will not be hurtful to the other person. Taking a personal inventory,
which is the topic of the next section, also helps to counteract the effects
of the shame and guilt of the addiction by giving the recovering person a
structure for facing up to and honestly taking account of the damaging
or bad behaviors engaged in during the active addiction. This inventory
leads to the possibility of making amends, which, in turn, can lead to letting go of the shame and guilt.
CASE EXAMPLE
Sandy, the recovering patient who seemed to be entering a relapse process, has relapsed. She feels so embarrassed and ashamed that she has
avoided two consecutive scheduled sessions. The counselor reaches her
by phone to discuss why she has missed the sessions, and she admits to
the relapse. She tells the counselor that she relapsed two weekends ago
after work with peers from her job. Since then, she has used twice, the
first time with the same peers and then 3 days ago by herself.
Interventions
52
1.
The counselor empathizes with how bad Sandy is feeling and persuades her to come in for a session. Sandy attends the session, and
the first thing they do is process the relapse. They clarify specifically
what and how much Sandy used, which is important in the interest
of Sandy’s being entirely honest with herself and the counselor
about what happened. They identify what external events and internal thoughts and feelings led up to her use, how she felt, and what
she did afterward. They spend most of the first session analyzing the
relapse.
2.
The counselor will want to communicate that they will work together to help Sandy get back on track. Further, the counselor will
want to encourage Sandy to recommit to her recovery, pointing out
that the counselor will support Sandy in resuming her recovery—she need not “go it alone.”
3.
Finally, the counselor will want to frame the relapse as a learning ex-
Chapter 9 Maintaining Abstinence
perience, the analysis of which can teach Sandy how to avoid these
pitfalls in the future.
Personal Inventory
Taking one’s personal inventory is a pivotal aspect of the recovery process, allowing the recovering addict to recognize what he or she has
been through and how he or she wants his or her life to be from this
point forward. If done truthfully and thoroughly, the inventory process
facilitates honesty with oneself and responsibility toward oneself and
others, in turn fostering greater self-acceptance. Although taking a personal inventory should be introduced at this point in treatment, the process should be repeated many times in recovery, so that each attempt is
done with increasing honesty and self-awareness on the part of the
patient.
The counselor should spend a full session talking with the patient about
the purpose, meaning, and procedures of taking a personal inventory.
The counselor should emphasize the importance of total honesty with
oneself in completing this task. The advantages to be gained via
increased self-knowledge and self-acceptance should be emphasized. If
the patient is involved with AA, NA, or CA, then taking a personal inventory should be a familiar idea. Therefore, the counselor and patient can
discuss the patient’s feelings about and preparations for this undertaking. If the patient is unfamiliar with the idea of taking a personal inventory, then the counselor can introduce and discuss the concept.
A personal inventory can be taken in several different ways. One way to
proceed is to ask the following questions of oneself and to write down
the answers.
Character Defects
1.
How does my addiction affect me—physically, emotionally, spiritually, financially, in terms of my self-image, and so forth?
2.
How does my addiction affect those around me—at home, at work,
financially, in social situations, as a role model for children, with regard to the safety of myself and others, and so on?
3.
What character defects in me feed the addiction—insecurities, fears,
anxieties, poor self-image, lack of confidence, excessive pride, controlling behavior, anger, and others?
After the recovering addict has learned to avoid the people, places, and
things that can lead to drug use and has established abstinence, he or
she may begin to recognize aspects of personality or character that are
obstacles to further recovery. Such obstacles are, in 12-step ideology,
“character defects.” They are typically recognized by the patient within
the process of undertaking the personal inventory discussed above. One
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outcome is that the individual notices qualities within himself or herself
that he or she might like to change.
“Character defects” are personality qualities that may impede recovery
from addiction or decrease the patient’s quality of life. These may either
have arisen as a result of the addiction or have existed previously and
contributed to the development of the addictive behavior.
Commonly Considered Character Defects
Inappropriate Anger
Self-Centeredness
Lust
Impatience
Overcriticalness
Low Self-Esteem
Exploitativeness
Overconfidence
Dishonesty
The patient’s efforts to change such defects should be encouraged by
the counselor. The following process is recommended for working on
changing defects.
The patient should:
1.
Identify problematic qualities in himself or herself, such as inappropriate anger, impatience, overconfidence.
2.
Decide what qualities to change by assessing how much control he
or she has over the undesirable trait and by determining whether it is
in his or her best interest to change.
3.
Make a commitment to work on changing the quality(ies).
4.
Seek the help of others when it may be appropriate
5.
Follow through on his or her commitment.
This process is the main approach to change in IDC, in a nutshell. Almost anything the patient seeks to change as part of recovery can be
looked at and dealt with using this process.
As a part of this process patients also should be urged to recognize the
positive qualities within themselves. Addicts often feel so much shame
and guilt that they have difficulty identifying positive aspects of themselves. In this case, the counselor should especially encourage patients
to identify good qualities about themselves and even to remind themselves of these positive things.
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Identification and
Fulfillment of Needs
Addicts often do not know how to get their needs met without using
drugs. Because an addict becomes so focused on obtaining and using
drugs, he or she loses touch with other, more important needs. Over
time some addicts fail even to recognize their other needs, much less
meet them. The counselor will discuss this problem with the patient and
determine if this is or ever was a problem. If this is a problem area, the
counselor will encourage the patient to talk about the specific instances
in which it occurs or has occurred.
Failures to recognize one’s needs can be situational. Often the feeling
that one does not have the right to have his or her own needs met can occur in a particular context. Examples include relational rights and privileges that stem from involvement with one’s family or spouse.
The counselor should explain the following concepts to the patient and
encourage the patient to practice assertive behavior. Assertive behavior
is a skill that can be learned and maintained through frequent practice.
n
Assertion is standing up for one’s personal rights and expressing
thoughts, feelings, and beliefs in direct, honest, and appropriate
ways that do not violate another person’s rights. The goals of assertion are communication and mutuality.
n
Nonassertion amounts to violating one’s own rights by failing to express honest feelings, thoughts, and beliefs and consequently allowing others to violate oneself. It also can occur through
expressing one’s thoughts and feelings in such an apologetic, diffident, or self-effacing manner that others easily can disregard them.
Unfortunately, assertion is often, through conceptual error, confused with aggression.
n
Aggression is standing up for one’s personal rights and expressing
thoughts, feelings, and beliefs in a way that often is dishonest, usually inappropriate, and always in violation of the rights of others.
The goal is domination and winning by forcing the other person to
lose. Winning is ensured by humiliating, degrading, or belittling
one’s opponent.
The counselor will encourage the patient to identify personal needs that
are not being satisfactorily met and, if appropriate, help the patient to
identify and try out the assertive behaviors to help get the needs met.
Giving patients the opportunity to rehearse repeatedly the assertive
communications and behavior they want to employ in problematic situations in their lives often is a useful intervention.
Management of
Anger
Many cocaine addicts have problems managing and expressing anger.
For some, drug use simultaneously both numbs and exaggerates emotions. Addicts often use drugs to suppress the anger that they feel, over
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time becoming numb to their true feelings. Because of the failure to recognize when one feels angry and to understand the reason for the feeling, this unacknowledged anger may explode. Addicts may also have
trouble dealing with their anger because, due to their addiction, they
may not have learned to express anger in a healthy, productive way.
They may have learned unhealthy ways to express their anger from their
parents or other role models. Further, addiction impedes the individual’s self-learning and emotional growth, so the recovering addict may
feel unable to deal with feelings. Also, addicts may be angry at themselves for their addiction but place the blame on others, so they misdirect their anger and vent it on those who are close to them.
The counselor should discuss how the patient experiences and expresses feelings of anger, including what things cause the patient to get
angry and how and with whom the patient expresses anger. Frequently,
managing anger is closely related to identifying and meeting needs. For
many, simply recognizing when one’s rights are being violated is the first
step in managing anger. Then, one can try to respond assertively and
avoid a less productive angry response. There are appropriate and inappropriate ways to express anger, and how the patient typically expresses
anger should be discussed. The counselor should help the patient to
identify more positive ways to express anger. Healthier ways of expressing anger may include assertive communications, possibly taking a
“time-out” from an argument and returning to the discussion later, or
having a physical outlet, like going for a run, lifting weights, or even hitting a pillow. The goal is for the patient to become able to manage feelings of anger more productively, without resorting to drug use or hurting oneself or others.
Relaxation and
Leisure Time
Relaxation, physical activity, and better nutrition contribute to a physically and emotionally healthy life. Involvement and improvement in
these areas is to be encouraged as part of the lifestyle changes a chemically addicted person has to make in order to progress toward recovery.
Recreation helps to support one’s recovery by providing relaxing activity that reduces stress and helps the patient to maintain a sense of balance in his or her life.
The counselor should discuss what kinds of healthy recreational activities the patient enjoys and, if necessary, encourage the person to resume
participating in them. If the patient does not currently participate in any
such activities, the counselor can help the patient to identify some leisure activities, new or old, that would be feasible.
Whenever possible, some form of physical activity should be undertaken
as part of one’s leisure time. In some cases, the patient should check
with his or her physician before starting any type of exercise, but this
step is less necessary if the patient is generally healthy and already engaged in some physical activity. Healthy exercise supports recovery in
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two ways. Engaging in physical activity helps to combat boredom, which
can be a major trigger for drug use. And it helps the recovering person to
feel better physically, which will hopefully lessen the severity of any
postacute withdrawal symptoms.
If the patient does not come up with suggestions for any physical activity
on his or her own, then the counselor should offer suggestions, including those on the following list.
Physical Activity Suggestions
n
Taking daily walks (in a pleasant area that will not trigger drug
craving).
n
Window shopping (which essentially involves walking), as long
as the recovering person does not have problems with compulsive spending. The advantage to this type of walking is that in bad
weather, one can do this activity inside in a mall or shopping center.
n
Fishing (many, predominantly male, patients enjoy this activity
but the counselor has to clarify that there must be no alcoholic
beverages on the fishing trips).
n
Joining a local health club or YMCA or YWCA.
n
Riding a bicycle, either to commute to and from work or other
places or just for pleasure.
n
Taking one’s kids to the park and playing with them. For younger
children, this activity usually means taking them to the playground;
for older kids, helping them improve their baseball, basketball, or
soccer skills might be appropriate. These activities offer the additional advantage of giving parents and children valuable quality
time together, which is important because the addiction has usually
damaged familial relationships.
n
Playing a sport that one used to enjoy, such as tennis, a summer
softball league, or “pick-up” basketball games at the neighborhood courts (as long as there is no alcohol or other drugs
involved).
A related area of recovery to emphasize is good nutrition. Addicts often
fail to eat properly either because the bulk of their time is spent in getting, using, and recovering from cocaine or because after supporting
their drug habit, they do not have the money to buy food. Additionally,
cocaine use temporarily suppresses one’s appetite, so if the addicted
person does not consciously try to eat well, he or she will tend to skip
57
Chapter 9 Maintaining Abstinence
meals because of not feeling hungry. Good nutrition helps the recovering person feel better physically by lessening the experience of postacute
withdrawal symptoms and rebuilds the body ravaged by addiction.
The counselor should discuss eating habits with the patient to determine
how aware he or she is about good nutrition. If the patient does not have
healthy eating habits, some nutritional suggestions should be offered.
The following are very basic suggestions for improving one’s nutrition.
Nutrition Suggestions
Employment and
Management of
Money
n
Patients should be encouraged to eat two or three healthy meals
a day and follow the Dietary Guidelines for Americans (USDA,
USDHHS 1990).
n
Choose foods from the different food groups, including meat,
poultry and fish; dairy products; fruits and vegetables; and bread
and grains. Five fruits and vegetables daily are recommended.
n
Many Americans eat too much processed sugar, too much fat,
and too much salt, which can contribute to common health problems such as diabetes, heart disease, high cholesterol, obesity,
and high blood pressure.
n
Balanced, nutritious meals are better and more economical if
prepared at home rather than purchased at fast food restaurants.
n
Eating more healthfully will give one more energy and help one
to feel better sooner in recovery.
Recovering addicts very often have problems maintaining employment
and managing money. Frequently, their drug use has caused them to be
irresponsible at work, which may have gotten them fired. By this point in
recovery, many addicts have thought about going back to work or seeking work. Many feel that they need to start working, so they can become
responsible people and support themselves and their families. While
these heightened inclinations for the patient to be more responsible are
to be encouraged, work situations themselves may cause major problems for the addict in recovery.
Although employment will add structure to the person’s life and may foster improved self-esteem, it is likely to be a significant psychosocial
stressor. To get a job, the patient may have to face fears of failing. Actual
failure, or even the associated fears, may result in further loss of
self-esteem. Employment is stressful for other reasons as well. The job
environment may be a source of stress because it is a situational trigger
for drug use. Such a situation would exist if the recovering person used
or bought cocaine on the job, and especially if peers use cocaine on the
58
Chapter 9 Maintaining Abstinence
job. Alternatively, an employee may have used drugs in the past to escape feelings of stress related to what he or she considered a highly
stressful job. In this case, the recovering person’s pattern may have been
to pick up cocaine after work every day or most days. Cocaine then
would be used ostensibly to help the addict unwind after the stressful
day at work.
These issues should be discussed with the patient in preparation for his
or her return to work or to the job market. If possible, the patient should
have ample time to focus on recovery before returning to work. The
counselor and patient must decide when the patient has been in recovery long enough to ensure that the return to employment will not trigger
a relapse to cocaine use.
Along with returning to work, patients must be able to manage their
money responsibly. Addicts in their active addiction phase are often irresponsible with money. For many addicts, having money is a powerful
trigger for cocaine use. If they have any money, they will buy cocaine.
Some addicts reach the point where they will spend all their money on
drugs and not have enough money to buy food or pay rent. Some cocaine addicts also engage in other forms of compulsive behavior with
money, such as gambling or compulsive spending.
The counselor should know from previous sessions whether money is
an important trigger for the individual patient. Whether money triggers
cocaine craving or not, the counselor should discuss money management issues prior to when the patient returns to work. If money is a trigger, the patient may be advised to put his or her money in the care of a
trusted person (often one’s mother). Obviously, any person the patient
wants to entrust with money should not be using drugs. Also, it may be
helpful to avoid having a card that allows him or her to withdraw money
from an automated teller machine. The physical act of going to the bank
and conducting the transaction requires time and planning and is not as
likely to lead to a drug run.
Transfer of Addictive
Behaviors
Addicts recovering from chemical addiction often believe erroneously
that recovery lies in transferring their addictive behaviors and may not
recognize this pattern as such. Addicts may become compulsively involved in other activities, such as work or exercise. The counselor
should warn the patient against transferring addictive behaviors, because compulsive behavior does not allow one to exercise free choice. It
may not be drug use, but it is compulsive behavior nevertheless and
therefore not within the individual’s control. The replacement of one’s
drug addiction with another compulsive behavioral pattern will not lead
to true sobriety in the long run.
The counselor and patient can examine the patient’s activities in recovery and find out whether the patient is prone to becoming compulsive in
59
Chapter 9 Maintaining Abstinence
his or her behaviors. So-called “workaholism” is a common compulsive
activity in recovery and can involve the patient working more than
full-time, spending a lot of spare time thinking about work, or spending
every waking moment in job hunting. Such behavior should be pointed
out to the patient as being compulsive and not beneficial to recovery.
To combat compulsive behaviors, patients should be encouraged to
make their recovery a first priority, to structure their days, and to make
sure that recovery-oriented activities have a prominent place in their
agendas on most days. The patient should be helped to identify and
meet personal needs. The importance of relaxation and participating in
leisure activities should be highlighted. The addicted person will greatly
enhance his or her chance to stay in a healthy recovery process if he or
she eats healthfully, exercises, sleeps well, avoids overscheduling and
overworking, and is able to relax.
There is one important exception to discouraging compulsive behaviors
in recovery: if the patient participates in AA, NA, or CA in a manner that
appears compulsive. If the patient identifies 12-step participation as the
major activity supporting recovery and feels that he or she needs to attend several meetings a day, then this activity should be supported by
the counselor. If a patient’s 12-step participation is indeed compulsive,
and he or she develops a dependency on groups rather than internalizing the important 12-step ideas, then this is a therapeutic issue for some
much later point in recovery. However, at this still-early point in recovery, the counselor’s best approach is to continue to support the participation with the hope that through exposure the patient will internalize
what he or she needs from AA, NA, or CA.
60
Chapter 10 Advanced Recovery
Advanced recovery is considered to continue throughout one’s life. Recovery from addiction is a change in lifestyle that includes maintaining abstinence as well as involving oneself in healthy relationships; getting good
nutrition, rest, and exercise; and working to resolve one’s personal problems with the goal of attaining a satisfying, fulfilling life. Having established this kind of lifestyle, the patient must now continue to lead it. In
this model, recovery is a lifelong process.
Ideally, in this time-limited model, counseling is concluding at the point
when the patient is entering advanced recovery. Theoretically, individual drug counseling is being terminated when the patient has established and maintained abstinence and been taught all the essential strategies for recovery and for living sober. At this point the patient is ready
to have greater independence and self-accountability in recovery. Also,
he or she should be ready to embark upon the higher level task of integrating recovery-oriented values into all aspects of life. Of course, in reality, patients will be terminating at different points in their recovery
process, particularly when the counselor is working with a time-limited
approach. In this model, tailoring the length of treatment to the individual’s needs is not possible.
Termination
The counselor should plan to discuss the patient’s thoughts and feelings
about ending treatment in the final active treatment session. The impending termination should be mentioned several sessions prior to the
last one in order to give the patient the opportunity to think about the
treatment experience. In the final treatment session, the counselor
should ask the patient to summarize his or her overall experience of the
treatment process. If possible, the counselor should recognize and compliment the patient’s achievements in recovery. A major goal is to identify the gains made through treatment. Another central goal is to recognize the areas still needing work and to plan how the patient will continue to work on them independently. The counselor should encourage
the patient to establish a personal commitment to continue in his or her
own recovery process. To this end, the counselor should urge the patient to specify the steps to be taken to establish his or her own recovery
61
Chapter 10 Advanced Recovery
process. The importance of continued participation in self-help groups
should be emphasized. Finally, the counselor should create the opportunity for the patient to discuss feelings about ending the counseling
relationship.
Treatment Booster Sessions
Following completion of the active treatment phase, patients can benefit from continuing to be seen by their counselors. They can use what
they have learned in the active phase of treatment and bolster that learning with less frequent booster sessions and continued participation in
self-help groups.
In the original research program, patients were seen once a month for 3
months for booster sessions. There was no empirical reason for choosing this particular length of time, so practical considerations should govern the choice of how long to continue the booster sessions. In the final
booster session, the counselor should revisit the termination issues that
were discussed at the end of the active phase of treatment.
The purpose of booster sessions is to provide continuing support for the
recovering individual, to encourage participation in a personal recovery
program, and to ensure that the person has assistance available if any
problems with maintaining abstinence should arise. The subject matter
discussed in the followup sessions should continue to be addiction-related and often will involve the repetition of earlier topics with a
new and higher level of understanding and integration.
Goals of Booster Sessions
62
1.
Provide a reminder to the patient of his or her commitment to
recovery.
2.
Offer support and feedback to the recovering person.
3.
Help the individual develop a personal program of recovery.
4.
Be available if a relapse or similar crisis should arise.
Chapter 11 Dealing With Problems That
Arise
Dealing With Lateness or Nonattendance
Patients are repeatedly urged to arrive for all sessions promptly, to call if
they are going to be late, and to call at least 24 hours in advance if they
must cancel a session. If a patient fails to fulfill these obligations, the
counselor will confront him or her about it in the session.
If a patient arrives late for a session, the consequence of that action is to
have a shorter session, because the counselor will, and should, end the
session on time. Repeated missed sessions without appropriate cancellations and rescheduling may eventually result in dismissal from the
treatment, which should be made clear to the patient. In the original research program, administrative termination of treatment occurred only
after 30 consecutive days of nonattendance, so patients were actually
given many chances to participate before being terminated from treatment for nonattendance.
Patients are requested to arrive “clean” for all visits. If a patient arrives
for a session obviously intoxicated, the counselor should remind the patient of his or her responsibility not to be high or intoxicated at sessions
and reschedule the session. Clinicians should use personal judgment
about how best to handle an individual event. For example, if a patient
arrives for a session mildly under the influence but not intoxicated
(blowing a low positive on a Breathalyzer®), the counselor must decide
whether to continue with the session or reschedule. This situation is
quite different from one in which the patient appears to have used just
prior to the session, for example, in the parking lot.
Denial, Resistance, or Poor Motivation
Denial and questionable motivation are central themes in the beginning
phase of addiction treatment. They are addressed in the initial sessions
of counseling and are repeatedly addressed, as needed, throughout the
course of treatment. The major strategy is to “chip away” at the patient’s
denial by pointing out the addictive behaviors and the actual conse63
Chapter 11 Dealing With Problems That Arise
quences of addiction and by appropriately confronting the patient on
the blindness of his or her denial.
Resistance is not a concept that is directly addressed as such in this addiction counseling model. In addiction counseling, much of resistant
behavior falls within the concept of denial and is addressed in that way.
For example, it would be denial if the patient refused to give up alcohol
(when cocaine is the drug of choice) or avoid drug-using friends because
of denial or minimization of the severity or consequences of the addiction. Another approach to dealing with resistance is to view it as the addict’s willfulness which can be overcome by surrendering one’s will to
one’s “higher power” in recovery—the meaning of the 12-step suggestion to “turn it over” or turn one’s will over to a “higher power.”
Regarding motivation, patients often express ambivalence at some point
in treatment. Several strategies may be used, including encouraging patients to review the pros and cons of getting sober or explore fully the
consequences of their addiction. Patients may also be asked to identify
specifically the benefits of sobriety in their life. Essentially, these issues
are reviewed continuously throughout the early period in treatment.
Strategies for Dealing With Crises
If the patient presents with an urgent, addiction-related problem like
marital dissolution or financial problems as a result of the addiction, the
counselor should try to address the problem. Emphasis should be placed
on how the problem is related to the addictive behavior. Considerable effort should be taken to help the patient develop strategies for dealing with
the problem in a manner consistent with recovery, including identifying
how to obtain appropriate assistance from social services.
If the patient presents with a true crisis, such as having spent all of his or
her money on a cocaine binge, and as a result, feeling suicidal, the counselor should address this issue immediately. The counselor may have to
organize a team effort among the appropriate treatment staff to provide
any medical or psychiatric services that the patient requires in order to
remain safe.
Dealing With Relapse
If a relapse occurs, the counselor and patient should use the session immediately following the relapse to identify and process the events,
thoughts, and feelings that precipitated the relapse. This step is called
relapse analysis.
Relapse to drug use is a common occurrence that can be emotionally
devastating to the patient. The counselor must communicate to the
64
Chapter 11 Dealing With Problems That Arise
patient that a relapse to drug use does not mean that the entire treatment program has been a failure. Recovery is definitely not all or nothing. There is a residual savings. When patients relapse, the counselor
will want to convey to them that they have lost their “clean time” but not
the knowledge and experience gained during their recovery. The counselor should educate the patient about relapse and about the importance of taking corrective action rather than being overcome by feelings
of depression or failure. Most episodes of drug use can be managed
without seriously interrupting the treatment program. They can be used
in a positive and educative way to strengthen the recovery process. In
dealing with a relapse, the counselor should use the general principle
that relapse is caused by failure to follow one’s recovery program. Thus,
the counselor should identify where the patient deviated from his or her
recovery plan and help the patient to recommit to the recovery program.
Levels of Severity of Relapse
Relapse can be viewed as having three levels of severity, which determine the appropriate therapeutic response. The counselor must understand the three types of relapse and the appropriate interventions to be
used in each case. The counselor should communicate to the patient
that any level of resumption of drug use is still a relapse, necessitating
analysis of the process and recommitment to one’s recovery program. In
other words, a “slip” still is a relapse. The levels of severity are to assist
the counselor in determining the appropriate action to be taken.
Slips
The least severe type of relapse is a “slip,” a common occurrence that involves a very brief episode of drug use associated with no signs or symptoms of the dependence syndrome, as specified using the DSM–IV criteria (American Psychiatric Association 1994). Such an episode can serve
to strengthen the patient’s recovery if used to identify areas of weakness
and point out solutions and alternative behaviors that can help prevent
future drug use from occurring.
Several Days of
Drug Use
The next most severe type of relapse is when the patient resumes drug
use for several days, and the use is associated with some of the signs and
symptoms of addiction. In such a case, the counselor probably would
want to intensify treatment temporarily, which can be effective. We have
found that intensified contact will usually reinstitute abstinence. The
patient should be encouraged to review what happened and learn from
the experience how to avoid a relapse in the future. The patient also
should be encouraged to recommit to his or her recovery program.
65
Chapter 11 Dealing With Problems That Arise
Sustained Drug Use
With Resumption of
Addiction
66
The most serious form of relapse is a sustained period of drug use during which the patient fully relapses to addiction. Often a patient who relapses to this extent also will drop out of treatment, at least temporarily.
In this case, if the patient returns to treatment, he or she may need to begin treatment with a detoxification phase, in either an inpatient or outpatient setting. The decision to detoxify a patient as an inpatient or an
outpatient should be made conjointly by the treatment staff involved.
Their decision should be based on the severity of the relapse, the particular drugs used, the availability of social support, and the presence of
unstable medical or psychiatric conditions.
Chapter 12 Counselor Characteristics
and Training
Ideal Personal Characteristics of the Counselor
Addiction counselors must exhibit good professional judgment, be able
to establish rapport with most patients, be good listeners, be accepting
of the patients (i.e., not have a negative attitude toward working with addicts), and use confrontation in a helpful rather than an inappropriate
or overly punitive manner. Competent addiction counselors also must
be personally well organized enough to be prompt for all sessions and to
maintain adequate and appropriate documentation.
For clinical purposes, the model presented here can be used easily by
skilled counselors in the field. It is not intended to serve as an alternative
to a formal educational experience. Rather, it is intended for use by
counselors who already have gained some experience in the area of addiction treatment. To prepare for the original research study, counselors participated in several 2-day training workshops that they typically
enjoyed and found helpful. Therefore, we would recommend a formal
training experience, if possible. When such an experience is not possible, reviewing the manual carefully and participating in ongoing supervision still can be helpful.
For research purposes, formal training and certification by recognized
experts from the Training Unit at the University of Pennsylvania/Veterans Affairs Medical Center is necessary. In addition, ongoing supervision based on the adherence scale is required to ensure consistency in
this particular model as well as high quality patient care.
Educational Requirements
In the field of drug counseling, experience is viewed as at least as valuable as formal education, so the range of formal education is broader
than in clinical psychology, for example. Generally the range of education is high school graduate to doctorate, with the majority of counselors having a bachelor’s or master’s degree in social work, counseling
psychology, or other human services field.
67
Chapter 12 Counselor Characteristics and Training
Credentials and Experience Required
Counselors are required to have a minimum of 3 years of experience in
addiction counseling and be knowledgeable of and use the 12-step
model. Professional certification for addiction counselors is available
from different State organizations as well as from a national organization. For example, in Pennsylvania one can be credentialed as an Associate Addiction Counselor (AAC) or a Certified Addiction Counselor
(CAC) through the Pennsylvania Chemical Addiction Certification
Board (PCACB). Professional certification and affiliations are encouraged but not mandatory. Since extensive experience is a requirement for
certification, many counselors work in the field for a while and then become certified.
Counselors in Recovery Themselves
Many counselors in this field are either in recovery themselves or have a
family member who was addicted. Our view is that an indepth knowledge of addiction and the tools for recovery and an ability to empathize
with the patient are essential attributes of an effective addiction counselor. One way, but not the only way, to acquire this knowledge and ability is to be in recovery oneself. If a counselor is in recovery, he or she
should be relatively emotionally healthy and stable. In practice, a minimum of 5 years in recovery should be required. In a setting that employs
multiple counselors, the optimal situation is to have recovering and
non-formerly addicted counselors, because this mix tends to foster the
greatest amount of learning from one another.
68
Chapter 13 Supervision
Training and Supervision
Ongoing supervision is a necessary and important part of counselor
training and support. A problem sometimes seen in the addiction field is
a lack of adequate supervision. Also, counselor stress and burnout are
commonplace. This constellation of phenomena—lack of adequate supervision, stress, and burnout—are seen frequently.
The ultimate goal of supervision is to enhance the quality of patient care.
Two primary foci help to achieve this goal. First, it is centrally important
to provide support and encouragement for the counselor and to promote the opportunity for counselors to expand their skills. Second, it is
important for the supervisor to have the opportunity to review the clinical status of the patients and to offer suggestions or corrections.
The format of supervision in this model is for each individual counselor
to have a supervisor and to meet with that supervisor once a week to review counseling sessions. We recommend that the individual counseling sessions be audiotaped and some of them reviewed by the supervisor. The supervisor should listen to a certain percentage of the sessions
in their entirety and then rate them for adherence to the counseling
manual. Then feedback can be given to the counselor, based on his or
her adherence to the model of addiction counseling, as well as other relevant clinical issues.
Use of the Adherence Scale
This manual is accompanied by an adherence scale (see Appendix II) to
assess the counselor’s level of adherence and compliance in providing
addiction counseling based on this model. The adherence scale has two
primary uses: training and supervision, which is important in clinical as
well as research programs, and measurement of treatment
differentiability, which is particularly important in research studies comparing different models of treatment. Here, we discuss only the clinical
use of the adherence scale.
The scale is designed to target and make explicit the specific kinds of
69
interventions that are central to addiction counseling. Counselors are
rated, on 7-point scales, on the frequency and quality (which are interpreted as adherence and competence) of relatively specific types of interventions recommended in the manual. Counselors should be clear
about what types of interventions they should be employing if they are
using this approach. The scale also identifies types of interventions that
should not be used because they are not theoretically consistent with
this approach. Furthermore, the adherence scale is intended to guide
trainers or supervisors in their duties supervising other addiction counselors. To this end, fairly specific instructions also are provided for how
to rate the interventions correctly.
Although the adherence scale identifies the types of interventions that
are necessary to conduct good addiction counseling as described by this
manual, not every type of intervention highlighted should be employed
in every session. Patients do differ from one another. Different issues
arise for individual patients at different points in treatment, and as various life events impact on the treatment. The adherence scale lists the
repertoire of interventions that addiction counselors will be making in
the string of counseling sessions. But, overall, the patient’s individual
needs in treatment should influence how and in what sequence these interventions actually are done.
The adherence scale, developed based on the IDC approach has been
evaluated with regard to its psychometric properties (Barber et al.
1996). There was satisfactory interjudge reliability, which indicates that
the scale can be used reliably to assess adherence and competence for
IDC techniques.
Also, there was a fairly high level of internal consistency within the five
main and two secondary subscales: monitoring drug use behaviors, encouraging abstinence, encouraging 12-step participation, relapse prevention, educating the client, miscellaneous, and things that should not
be done. This finding supports the grouping of items into subscales,
which then creates an easier way of understanding the theoretical types
of interventions in this model.
Substantial correlations between adherence and competence imply that
experts in the field thought that counselors who made better use of the
interventions identified in the manual also were more skillful in their
counseling style in general. This finding suggests that the IDC model incorporates many of the valuable ideas and interventions in the area of
addiction counseling. Further, it probably suggests that skilled addiction counselors will be fairly comfortable employing this approach because it is consistent with what good counselors generally try to do.
Finally, the adherence scale has shown good discriminant validity, implying that experts in the field can distinguish this model from other
treatment models, including cognitive therapy and supportive70
Chapter 13 Supervision
expressive psychodynamic therapy. For the original research, we compared these different treatments for cocaine addiction and determined
that IDC was particularly effective.
71
72
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With Opiate Addicts.” Unpublished manuscript, University of Pennsylvania, 1977.
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Appendix: Adherence/Competence
Scale for Individual Drug Counseling (IDC) for
Cocaine Dependence
D. Mercer, N. Calvo, I.D. Krakauer, and J.P. Barber
University of Pennsylvania
Counselor No: _______________________________________
Patient No:_________________________
Session No:__________________________________________
Session Date:_______________________
Rater:_______________________________________________
Date Rated: ________________________
Please rate the counseling session using the scale below. For each item, rate both the frequency (how much
the counselor engaged in the described behavior) and the quality (how competently the counselor carried
out the behavior) on the blanks to the left of the item. When rating quality, be sure to take into consideration the context of the session and the timeliness of the intervention. Use the 7-point rating scale below
for both ratings.
Frequency:
Quality:
1: did not occur at all
1: extremely poor, possibly detrimental to patient
2: passing comment, briefly touched on
2: poor (vague, critical, judgmental)
3: some, mentioned, briefly discussed
3: mediocre (implicit, rambling, poor focus)
4: moderate level of frequency
4: acceptable
5: pretty frequent
5: good quality
6: very frequent
6: very good quality
7: exceptionally frequent
7: excellent quality
If the behavior described in an item did not occur at all, rate frequency 1 and rate quality according to how
detrimental the exclusion of the intervention was to the patient. If it was extremely bad that the counselor
did not carry out the intervention, rate quality 1; if it was acceptable that the counselor did not carry out the
intervention (it was not necessary in the context of the session, or the patient carried it out spontaneously)
rate quality 4; and if it was excellent that the counselor did not carry out the intervention, rate quality 7. Do
not use a rating of “not applicable” for either frequency or quality.
1
Low
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2
3
4
Moderate
5
6
7
Very high
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Appendix
MONITORING DRUG USE BEHAVIORS
Frequency Quality
______
______
1.
Monitoring cocaine usage
Give a frequency rating of 4 (or above) if this occurs and a rating of 1 if it does
not. A frequency rating of 4 may be given even if the counselor does not explicitly
ask about cocaine use (i.e., “Have you used any drugs at all since we last met?”).
A lower quality should be given in this instance, however. To receive a high quality rating, the monitoring must be done at the beginning of the session.
______
______
2.
Monitoring other drug/alcohol usage
Give a frequency rating of 4 (or above) if this occurs and a rating of 1 if it does
not. Rate quality according to how completely and competently it is covered. To
receive a high quality rating, the counselor must do a full drill at the beginning
of the session and establish the date of last use.
______
______
3.
Monitoring craving
At least one specific question must be asked to get a rating of 4 or above. Sample
questions: “Did you want to use this week?” or “Did you have any cravings/urges
this week?”
______
______
4.
Monitoring high-risk situations (situational triggers)
The situations must be explicitly tied into drug use to get a rating of 4 or above.
______
______
5.
Monitoring emotional triggers (feelings that can lead to drug use)
The feelings must be explicitly tied into drug use to get a rating of 4 or above.
Sample question: “Have those feelings led you to pick up?”
______
______
6.
Monitoring withdrawal or postacute withdrawal symptoms
This must occur specifically within the context of a discussion on withdrawal/postacute withdrawal symptoms. To receive a rating of 4 or above, specific monitoring questions must be asked.
ENCOURAGING ABSTINENCE
Frequency Quality
______
______
7.
Helping the client structure his/her time
To get a rating of 4 or above, the counselor must offer plans or suggestions or discuss concrete ideas.
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______
______
8.
Discussing current employment and/or money management
______
______
9.
Discouraging drug and alcohol use
If only implicit, do not rate frequency above 4.
______
______
10. Discussing client compliance or resistance to treatment
This should be concrete, referring to the treatment plan and whether the client is
doing what s/he agreed to do (i.e., meetings, group therapy, abstinence, phone
calls, etc.).
______
______
11. Helping the client to develop healthy social skills and/or recreational
activities
______
______
12. Encouraging personal responsibility for recovery
______
______
13. Reviewing consequences of drug/alcohol use
This refers to past or progressing consequences, rather than future or possible
ones. Also, consequences should relate directly to the client.
______
______
14. Discussing issues of spirituality
ENCOURAGING 12-STEP PARTICIPATION
Frequency Quality
______
______
15. Monitoring attendance at 12-step groups
Includes frequency of attendance and type of group.
______
______
16. Encouraging attendance at or involvement in 12-step programs
Includes suggesting that the client get a sponsor, attend more meetings, attend
different types of meetings, etc.
______
______
17. Discussing specific steps and 12-step philosophy (i.e., steps, philosophy,
traditions, and slogans)
______
______
18. Examining client’s concerns about or resistance to any aspect of the
12-step program
______
______
19. Discussing sponsor-sponsee relationships
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Appendix
RELAPSE PREVENTION
Frequency Quality
______
______
20. Discussing stressors and how they influence recovery
Stressors refer to any ongoing external situation to which the client must adapt
(e.g., employment, relationships, kids). The counselor must specifically tie the
stressor into recovery (e.g., “Does that make you want to use?” “What can you do
instead of using?” “How does this affect your recovery?” “Has this led you to use
in the past?”) to receive a rating of 4 or above. If the patient complains but the
counselor does not respond, F=1. Frequency reflects the presence of discussion,
and quality reflects the helpfulness of discussion.
______
______
21. Confronting denial and ambivalent feelings
______
______
22. Processing most recent relapse
This includes the people, places, and things of the relapse (i.e., what happened
when the relapse occurred).
______
______
23. Addressing relapse symptoms
This should occur in the context of relapse prevention and includes identifying
specific relapse symptoms. Changes in thoughts, attitudes, and behaviors count
as relapse symptoms.
______
______
24. Establishing concrete behavioral changes to get out of the relapse
process
Includes questions, such as “How can you interrupt it?” and “What can you do
differently?” as well as interventions, such as formulating safety or crisis plans.
An actual relapse does not have to have taken place; change in attitude, behavior, and thinking counts here as part of the relapse process.
EDUCATING THE CLIENT
Frequency Quality
______
______
25. Teaching about drug triggers
______
______
26. Teaching about withdrawal and postacute withdrawal
______
______
27. Teaching about the process of addiction/chemical dependency
Includes talking about the stages of addiction, tolerance, diagnostic criteria,
etc., in a didactic manner that is informative and declarative.
______
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______
28. Teaching about the relapse and/or recovery process
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______
______
29. Teaching about high-risk sexual behaviors (especially HIV-related ones)
and/or the cocaine-sex connection
MISCELLANEOUS
Frequency Quality
______
______
30. Dealing with anger (how to acknowledge the feeling and express it
appropriately)
If this behavior does not occur (F=1), rate quality low only if it is clear that the
patient does have feelings of anger that need to be addressed. If the patient explicitly states that s/he is angry and the counselor ignores it, rate F=1, Q=1. If
the patient implies that s/he may be angry (e.g., describes a situation in which a
person would typically be angry) and the counselor ignores it, rate F=1, Q=3. If
the patient does not mention anything in the session that indicates there may be
anger issues, rate F=1, Q=4. For F > 1, the counselor must offer concrete suggestions for how to deal with anger to receive a quality rating of 4 or above.
______
______
31. Discussing management of postacute withdrawal symptoms (e.g.,
encouraging good nutrition, good sleeping habits, and physical exercise)
To receive a rating of 4 or above, the counselor must suggest concrete behavioral
changes tailored specifically to the patient and her/his circumstances.
______
______
32. Addressing other compulsive behaviors (i.e., gambling, sex, overworking,
eating, thrill-seeking).
If this behavior does not occur (F=1), rate quality low only if it is clear that the
patient does have a compulsive behavior that needs to be addressed. Quality
ratings depend both on the counselor’s response and the degree to which a problem seems to be present. If the patient explicitly states that s/he has a problem
with a compulsive behavior and the counselor ignores it, rate F=1, Q=1. A rating of F=1, Q=4 is equivalent to N/A, meaning that the counselor does not address the problem, and there does not seem to be a problem to discuss. As Q approaches 1, it becomes more obvious that there is a problem. For Q > 4, the therapist must address the problem, and Q approaches 7 as the intervention becomes more helpful.
______
______
33. Discussing specific unhealthy relationships
______
______
34. Discussing family issues (codependency, enabling, alcoholism, etc.)
This item only refers to family issues that are related to drug use and/or other
negative behaviors. The focus must be on the way that these issues affect the patient. The counselor must explore the ways in which family issues relate to recovery for Q > 4.
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Appendix
THINGS THAT SHOULD NOT BE DONE
For these items, only frequency should be rated.
Frequency
______
35. Pointing out client’s dynamic themes in relationships
______
36. Interpreting aspects of the client’s relationship with the counselor
______
37. Identifying client’s dysfunctional cognitions about addiction
Refers to the cognitive model in which the therapist identifies the dysfunctional
cognitions and then engages the client in a cognitive process of developing cognitive coping strategies.
______
38. Encouraging client to use cognitive coping strategies
SUMMARY
Quality
______
39. Overall performance as an IDC counselor
A rating of 4 means that the counselor was an acceptable IDC counselor. A rating below 4 means that the counselor was unacceptable in some way—s/he did
not adhere to the IDC manual, exhibited inappropriate behavior, was a poor
counselor, etc. A rating above 4 means that the counselor was an especially
good IDC counselor.
______
40. Overall judgment of the level of difficulty presented by the patient
How difficult do you think this patient was to treat? If the patient was easy, rate
her/him low (1, 2, or 3). If the patient was difficult, give a high rating (5, 6, or 7).
A rating of 4 means that the patient was of about average difficulty.
1 = not difficult at all
7 = extremely difficult patient
TREATMENT MODALITY
Y/N
Confidence
______
______
41. Is this an Individual Drug Counseling session? (Y/N)
How confident are you of your answer?
1 = not at all confident
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4 = fairly confident
7 = absolutely certain
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______
______
42. Is this a Cognitive session? (Y/N)
How confident are you of your answer?
1 = not at all confident
______
______
4 = fairly confident
7 = absolutely certain
43. Is this a Supportive-Expressive Psychodynamic session? (Y/N)
How confident are you of your answe?
1 = not at all confident
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4 = fairly confident
7 = absolutely certain
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